■=^^ X-li* 

<&efaly4t 1 =M 

UNITED STATES OF AMERICA. 



* * 






DIPTHERIA: 



NATURE, HISTORY, CAUSES, PRETENTION, 



AND 



feattimti on Uggienk |Jrittri]jIes 



WITH A 



RESUME OP THE VARIOUS THEORIES AND PRACTICES OF 
THE MEDICAL PROFESSION. 



BY 



R. TV TRALL, M.D., 



AUTHOR OF THE "HYDROPATHIC ENCYCLOPEDIA," AND OTHER WORKS; PRINCIPAL 

OP THE HYGEIO-THERAPEUT1C COLLEGE ; PHYSTCIAN-IN-CIIIEF TO THE NEW 

YORK HYDROPATHIC AND HYGIENIC INSTITUTE, ETC., ETC., ETC. 



J ^, 

NEW YORK : 

Fowler and "Wells, ^Publishers, 



No. 308 BROADWAY. 
1862. 



JtT f**<i/A/fc 




iW 



Entered, according to Act of Congress, in the year 1S62, by 

E. T. TEALL, 

In the Clerk's Office of the District Court of the United States for the Southern 
District of New Tort. 



•X | §• r 



Daviks <fe Kent, 

BTEREOTYPERS AND ELKCTROTYPKRS, 

113 Nassau Street, N. Y. 



H\.\v 



^* \ 



PREFACE. 



The increasing prevalence of the malady known as diptheria, in 
various parts of the United States, the disastrous results of drug- 
medication, and the superior safety and efficacy of the Hygienic or 
Hygeio-Therapeutic method of treatment, supply the motive for 
presenting the public with a monograph on the subject. During 
the last two years I have been written to for information by 
hundreds of heads of families, in neighborhoods where two, three, 
four, 1ive y six, seven, eight, and in one case nine members of the 
same family have died of this disease, or of the treatment, or of 
both combined ; and everywhere the physicians seem to be in 
doubt as to its real pathology or proper treatment, while the people 
are in consternation because of its direful ravages. It has been my 
fortune to see much of the disease, and to have been in correspond- 
ence with many of the graduates of my school, as well as many 
other professional and non-professional persons who have success- 
fully applied the plan of treatment recommended in this work. 
And these circumstances have induced me to collate the substance 
of nearly all that has been published on the subject in this country 
and in Europe, and to note the facts and statistical data which have 
been presented to the profession and the public through the 
medium of the journals of the different medical schools. The 
work, therefore, here offered to the public is intended not only as 
an exposition of the true pathology and proper management of dip- 
theria, but as a record of all that is important which has been 
ascertained in relation to the disease and its treatment to this 

date. 

E. T. T. 

New York Hygienic Institute, No. 15 Laight Steeet. 



CONTENTS. 



PAGB 

Nosology and Technology of Diptheria 7 

Description of Diptheria 10 

Pathology of Diptheria 38 

The False Membrane 65 

History of Diptheria 76 

Infectiousness 87 

Causes of Diptheria 95 

Mortality of Diptheria 103 

Complications 116 

Sequelse of Diptheria 120 

Morbid Anatomy of Diptheria 134 

Drug Treatment of Diptheria 158 

Hygienic Treatment of Diptheria 227 

Tracheotomy 258 

Stimulation vs. Antiphlogistication 261 



DIPTHERIA. 



NOSOLOGY AND TECHNOLOGY. 

The malady now generally known as diptheria, 
diptherite, or diptheritis, has been a perplexing theme 
to the nosologists ever since its first recognition as a 
distinct disease. Some have classified it with croup; 
others have regarded it as a modification of malignant 
scarlatina, while others have considered it to be an 
affection sui generis. It certainly presents many of 
the characteristics of that form of scarlet fever which 
has prevailed extensively in many places under the 
name of putrid sore throat, while the exudation of a 
fibrinous material on the mucous surfaces seems to ally 
it closely with croup. 

The term diptheritis, in its most literal signification, 
implies inflammation of the shin. By some authors 
it is employed in a generic sense, to include all affec- 
tions of the mucous membrane characterized by the 
exudation of any material capable of coagulating or 
concreting into a membranous covering or coating. In 
this sense it comprehends the true croup, this being a 
variety or species of diptheritic inflammation. 

Professor George B. Wood, M.D., of Philadelphia 
(Wood's Practice of Medicine), denominates \t pseudo- 
membranous inflammation of the fauces. The term 
membranous quinsy — angina membranacea — has been 
applied to it by some authors. Stomatitis and follicu- 
lar inflammation are also among the numerous techni- 



8 DlPTHEKIA. 

calities with which a medical literature, more wordy 
than wise, has served to confuse and mystify the sub- 
ject. 

M. Bretonneau, who first explained the precise nature 
of the excretion of the disease, applied the term dipthe- 
ritis to a group or class of diseases which affect the 
dermoid tissue — the skin and mucous membranes — and 
which are characterized by a tendency to the formation 
of false membranes. In this sense, the term would be 
applicable to certain cases of catarrh in the bladder, 
tubular diarrhea, and dysmenorrhea, for, in all of these 
cases, there is frequently a similar exudation of lymph, 
and the formation of preternatural membranous con- 
cretions, which are cast off in fragments, and often 
accompanied, especially in the case of the uterine 
affection, with excruciating suffering. These morbid 
membranous formations have not unfrequently been 
mistaken for a sloughing or casting off and discharge 
of the mucous membrane itself. 

A malady closely allied, if not identical with dip- 
theria, or scarlatina maligna, has prevailed as an 
epidemic among domestic animals as well as among 
human beings. Thirty or forty years ago it prevailed 
extensively in western New York, and was there 
termed "black tongue" It was very fatal, as is the 
disease of human beings known as " putrid sore throat." 

" The medical history of the present century," says 
Edward Headlaw Greenhow, M.D., of St. Thomas' 
Hospital, London, in a late work on diptheria, "is 
remarkable for the reappearance in this country of two 
very definite forms of epidemic disease described by 
the physicians of former centuries, but unknown to 
our immediate predecessors. I have elsewhere shown 
that the disease which in our dav is called Asiatic or 



Nosology and Technology. 9 

epidemic cholera, is identical with a disease named 
dysenteria incruenta by Willis, and diarrhea colliqua- 
tiva by Morton, which prevailed during many years 
of the middle and latter part of the seventeenth cen- 
tury. The kind of epidemic sore throat, now called 
diptheria, which has prevailed so extensively daring 
the last four years, though unknown to the last two or 
three generations of physicians, was familiar to the 
medical practitioners of this country about the middle 
of the eighteenth century, under the names of malig- 
nant sore throat, epidemic croup, and morbus strangu- 
latorius. Both cholera and diptheria have, it is true, 
been observed from time to time in a sporadic form ; 
and small outbreaks of each of these diseases have 
sometimes occurred — but in an epidemic form they 
had been long unknown, when they reappeared in our 
own time." 

"The terms cholera and diptheria are, generally 
speaking, and perhaps properly, only applied to the 
malignant forms of these epidemic diseases, to the 
exclusion of the milder and commonly more numerous 
cases of illness induced by the epidemic influence. 
These milder cases, although characterized by an affec- 
tion of the same mucous surfaces, lack the more strik- 
ing features usually understood to be associated with 
the terms cholera and diptheria. The mucous surface 
of the alimentary canal is alike the seat of the princi- 
pal phenomena, both in cholera and the diarrhea 
which commonly prevails so extensively during a 
visitation of cholera. The mucous membrane of the 
throat, especially of the tonsils and immediately adja- 
cent parts, is not only the seat of the simpler form of 
sore throat which has prevailed so extensively during 
the last three or four years, but is likewise, almost 

1* 



10 DiPTHERIA. 

invariably, the situation in which the first symptoms 
of the more severe cases, properly termed diptheria, 
manifest themselves. The diarrhea of cholera times 
does not present the excessive prostration, the blue, 
cold, clammy surface, the pulseless extremities, or the 
whispering voice of fully developed cholera ; the sim- 
pler sore throats which have usually prevailed simul- 
taneously with diptheria have been often unattended 
by the characteristic exudation of false membrane, or 
by the prostration of strength, and have rarely, if 
ever, been followed by the rancous nasal voice, the 
paralysis of the muscles of deglutition or of locomo- 
tion, and the impaired vision which so frequently fol- 
low in the train of diptheria; but the diarrhea and 
sore throat are respectively congeners of cholera and 
diptheria, from which their difference is less one of 
character than of degree." 

Dr. Greenhow limits the term diptheria to the 
inflammation of mucous surfaces characterized by 
membranous exudation, but employs it generically to 
comprehend all forms of sore-throat affection attended 
with this exudation. 

DESCRIPTION OF DIPTHERIA. 

The following description of the disease, taken sub- 
stantially from the late work of Dr. Greenhow, is the 
most accurate and carefully drawn of any which I 
have seen, as applicable to the great majority of cases: 

" Diptheria, comparatively rare as a sporadic disease, 
prevails as an epidemic, in which form it often exists 
cotemporaneously over considerable tracts of country, 
or it may occur in smaller groups, limited to particular 
hamlets, or even to particular houses. Sometimes it 



Description. 11 

has prevailed so extensively that distant countries, in- 
cluding portions both of the Old and New World, 
have been simultaneously or successively visited by it. 

"Diptheria is sometimes preceded, and usually ac- 
companied, with fever, which, in certain epidemics and 
in severe cases, is only transient, speedily giving place 
to depression. There is often a stiffness of the neck at 
the commencement of an attack, and usually more or 
less swelling and tenderness of the glands at the angles 
of the lower jaw. The tonsils are commonly swollen, 
and, together with the immediately contiguous parts 
of the mucous surface, more or less inflamed. Some- 
times the swelling and inflammation subside without 
further local mischief; at others, the inflamed surface 
presents, from an early stage of the disease, whitish 
specks, or patches, or a continuous covering of a mem- 
braniform aspect, which may appear as a mere thin, 
almost transparent pellicle, but usually soon becomes 
opaque, and in some cases assumes the appearance of 
wet parchment or chamois leather. This membranous 
concretion varies in color from being slightly opaque 
to white, . ash-color, buff, or brownish, and in rarer 
instances to a blackish tint. — -- 

" This false membrane is a true exudation which has 
coagulated upon the mucous surface, from which it 
may often be readily separated, leaving the subjacent 
membrane mostly unbroken, or merely excoriated, 
usually reddened, vascular, tender, and dotted with 
small bloody specks or points, but sometimes super- 
ficially ulcerated, and more rarely in a sloughing con- 
dition. "When the false membrane has been artificially 
removed, it is apt to be renewed ; and when not med- 
dled with, to become thicker by continued exudation 
from the mucous surface. The severity of the disease 



12 DiPTHERIA. 

is commonly in proportion to the continuity and dens- 
ity of the exudation ; but cases sometimes occur in 
which the membranous exudation is inconsiderable, 
and yet the general symptoms are of a very alarming 
kind. If the patches are small and remain distinct, 
the case ordinarily runs a favorable course ; if they 
rapidly spread and coalesce, if the membrane becomes 
thick, and especially if it assumes a brownish or 
blackish color, danger is imminent. In proportion as 
the membrane increases in thickness and density, does 
its attachment to the subjacent surface generally be- 
come firmer. The surface of the mucous membrane 
around the exudation is red and vascular, and so tender 
that in severe cases it bleeds on the slightest touch. 

" The throat is in general the primary seat of the 
disease ; but the inflammation is apt to spread along 
continuous mucous surfaces, and thus to extend up- 
ward into the nares and to the conjunctiva; down the 
pharynx into the esophagus ; through the glottis into 
the larynx, trachea, and downward into the bronchial 
tubes ; or forward on to the buccal mucous mem- 
brane, the gums, and lips. Wounds and excoriations 
of the skin, and the mucous membrane of the nymphse 
and vagina when tender or irritated, especially in 
persons already suffering of diptheria of the throat, 
are during an epidemic liable to undergo the same 
process of exudation, which, coagulating, forms a false 
membrane analogous to that on the tonsils and throat. 

" Albuminaria, commencing early in the disease, 
usually within a few hours, and gradually disappear- 
ing with the local affection, sometimes, but by no 
means invariably, accompanies diptheria. If the urine 
be much loaded with albumen, the complication is a 
serious one ; but cases have done well in which a con- 



Description. 13 

siderable cloud of albumen was deposited from the 
urine by the proper tests, and very severe and fatal cases 
of diptheria have been unattended with albuminaria. 

" After a time the false membrane is thrown off, 
either entire, so as to represent a mold of the parts it 
covered, or, which is more usual, comes away in shreds 
or flakes, intermingled with mucus. Sometimes it 
undergoes decomposition prior to separation, giving 
rise to a very offensive smell. When the membrani- 
form exudation has come away spontaneously, it is 
sometimes repeatedly renewed, each successive false 
membrane becoming less and less dense, having less 
and less of the character of exudation, and more and 
more of that mucous secretion, until at length the 
affected surface is merely covered with a thick mucus, 
which gradually disappears as the mucous membrane 
recovers its healthy condition. In other cases the 
exudation is not renewed when it has once been thrown 
off, but the subjacent membrane is observed to be 
either redder or paler than natural, has a rough, rug- 
ged appearance, or is depressed below the adjacent 
surface on the parts where dense false membrane has 
existed. Occasionally sloughing takes place beneath 
the exudation, or even more deeply, as in the center of 
a tonsil, and may implicate the tonsils, uvula, and soft 
palate. More rarely the tonsils suppurate. Hemor- 
rhage from the nose and throat, independently of the 
co-existence of purpura, often occurs in the course of 
diptheria, and is sometimes very profuse. The local 
affection may pass into a chronic form, in which re- 
lapses or exacerbations are readily produced by vicissi- 
tudes of weather, or by exposure to damp or cold. 
Even perfect recovery from an attack affords no im- 
munity from the disease in future. 



14: DlPTHEEIA. 

" A peculiar character of the voice, resembling that 
produced by affections of the throat in secondary 
syphilis, is a common result of diptheria, and often 
continues for many weeks after recovery. The power 
of swallowing is sometimes so impaired that there has 
been difficulty in sustaining life during convalescence ; 
and the liquids especially are apt, even after a com- 
paratively slight attack of the disease, to be re- 
gurgitated through the nostrils. Extreme anemia, 
impairment of vision, a peculiar form of paraplegia, 
weakness of the hands and arms, numbness, tender- 
ness of the limbs, tingling, wandering pains, and more 
rarely, nervous sequelae of a hemiplegic character, are, 
in the order here written, ulterior consequences of 
diptheria. Gastrodynia, and sometimes dysenteric 
diarrhea, occasionally follow diptheria. Pain of the 
ear, deafness, and abscess are occasional but rare 
results of the disease." 

In Braithwaite's Retrospect for January, 1860, is a 
graphic and very accurate description of the disease in 
its severer form, by James P. McDonald, Esq., of 
Bristol, England, who has treated a large number of 
cases : 

" I consider diptheria to be a disease produced by a 
specific poison taken into the system, acting through 
the blood and seen at the throat." 

In the above passage the author confounds the 
poison itself, or cause of the disease, with the effect. 
"What is seen at the throat is not the specific poison 
which induces the disease, but the excretion by means 
of which the living system undertakes to cleanse itself 
of the morbific material, and the idea that the poison 
" acts through the blood" is a part of the false theory 
of disease entertained by the whole medical profession. 



Description. 15 

Poisons do not act on nor through the blood, nor any 
of the tissues or organs. They do not act at all. But, 
on the contrary, the living machinery acts to expel 
them, and this expulsive process is the disease, strange 
as this announcement may sound to ears unaccustomed 
to regard disease as a process of purification and rep- 
aration — a remedial effort. 

Mr. McDonald continues : " The following are the 
usual form and course of the disease in its severest 
type. The patient is suddenly (and generally in the 
morning) seized with violent vomiting of a thin, yel- 
lowish-white matter of a very offensive character ; then 
purging of a fluid of similar appearance and smell. 
These dejections last an hour or so, and are followed 
by great prostration and stupor. The patient lies for 
a period varying from six to sixteen hours in a heavy 
sleep, from which he is with difficulty aroused, and 
then only to sleep again. The skin is hot ; pulse 100 ; 
the tongue is of a bright red ; drink is taken with 
avidity, if offered, but only to be immediately returned. 
And now the important question is put, ' Is the throat 
sore V The answer is always the same — ; not in the 
least? The reply, to the inexperienced in the horrible 
malady, may be fatal to the patient. The diagnosis is 
that this is not a case of diptheria. On the other hand, 
the experienced man expects this reply ; he forthwith 
carefully examines the throat, and then he sees the dis- 
ease. In this early stage the tonsils, the soft palate, 
and the back of the pharynx present a bright, shining 
red appearance. The small vessels are not seen indi- 
vidually injected, as in many forms of sore throat, but 
the appearance is as though the parts had been brightly 
painted and then varnished. Hanging from the velun\ 
to the tongue is seen, in this stage, a transparent film 



16 DlPTHERIA. 

of a tenacious fluid, which is burst by expiration, send- 
ing its particles over the mouth and the instrument 
used to depress the tongue. The next moment a sim- 
ilar curtain is formed. After a period varying from 
six to sixteen hours, the condition of the patient mate- 
rially changes. The stupor has passed off, and delir- 
ium, often of a violent character,' takes its place; there 
are the usual symptoms of cerebral excitement, and the 
fever runs high ; breathing is quickened ; the voice is 
changed to a thick yet shrill tone ; there is a short, 
dry cough (in children evidence of coming croup) ; the 
neck is puffy and blushed ; the tongue is coated with 
a white fur, and all those parts hitherto so brilliantly 
red, are thickly spotted with a whitish substance, 
which, in a wonderfully short period, conglomerates 
and forms one thick, plastic deposit, which in time 
may cover the whole palate to the teeth, so that the 
appearance, on opening the mouth, is as though it were 
lined with plaster-of-Paris. The violent delirium then 
subsides ; the powers of life fail rapidly ; the horrible 
sensations of choking and suffocation come on ; the 
sufferer tears at his neck with his nails, and tries to 
open his mouth, yet full power of swallowing still con- 
tinues, and he greedily gulps anything given him in 
the shape of drink ; large livid spots form on the ex- 
tremities, amounting sometimes to purpura ; the diar- 
rhea, of a white and offensive matter, is increased; 
muttering delirium comes on, and in a long tetanic 
convulsion, death closes the scene. 

"This is a truthful picture, .drawn from realities, of 
how a previously strong and healthy man may, in six 
days or less, cease to be. 

" Taking the above as a fair example of diptheria in 
its most marked and deadly aspect, as I have seen it, 



Description. 17 

we get the resemblance to it, more or less, in all minor 
cases. We must not expect to meet with all the symp- 
toms in every case, but the condition of the throat is 
invariable. Whether that condition goes on to the 
second stage, depends on the severity [quantity?] of the 
poison or the success of the treatment adopted. In all 
cases where there is either nausea or vomiting, followed 
by drowsiness, the throat ought to be examined, and 
if the redness and the ' glassy curtain' appear, the im- 
mediate use of the proper appliances may, I am quite 
certain, save many valuable lives." 

In the same journal is an article from the pen of 
Thomas Heckstall Smith, Esq., surgeon to St. Mary 
Cray, Kent, who distinguishes three forms of dipthe- 
ria : " There are three forms in which the disease pre- 
sents itself, viz., simple ash-colored diptheria membrane 
in patches, with very slight congestion of the surround- 
ing parts, and without fetor. Secondly, a deeper color, 
and more widely-spread membranous exudation, with 
fetid breath and intense engorgement of dark hue. 
Thirdly, the membrane with much tonsillitis, in a few 
cases resulting in quinsy. But there has been a fourth 
and more formidable state of things to contend with, 
namely, an extension of the membrane in either of the 
above forms, to the larynx and trachea, the symptoms 
of which I need not describe." 

In a paper read before the New York Academy of 
Medicine, January, 1861, by David Winne, M.D., of 
the University Medical School, the symptoms are thus 
described : " Diptheria is frequently attended with very 
slight constitutional disturbance at the commencement 
of the attack, even where the disease is destined to a 
fatal termination. The patient is often so little af- 
fected, that, with the exception of some slight difficulty 



18 DlPTHERlA. 

in the act of deglutition, he exhibits no evidences of dis- 
ease, and it is with difficulty that the parents can be 
brought to consider this symptom as one of much im- 
portance, or the child in very serious danger. 

" After a short interval, however, one of the tonsils 
— seldom both — becomes specked with a yellowish- 
white deposit, which, when seen at this early stage, 
presents the appearance of small whitish stars in the 
midst of a ground of what appears to be a transparent 
layer of mucus, but which really is the true diptherial 
membrane through which the body of the tonsil, often 
of an increased redness, is distinctly seen. These spots, 
small at first, rapidly enlarge, the membrane loses its 
transparency, and if not speedily arrested, spreads over 
the soft parts of the palate, both tonsils, the uvula, and 
involves the larynx, and sometimes the trachea and 
bronchial tubes. 

" Usually, even in slight cases, the local symptoms 
are preceded by some constitutional disturbance. There 
is a feeling of malaise, pain in the head, often extend- 
ing to the neck ; lassitude, and more or less fever. In 
the mild form the tongue presents a thick creamy coat, 
through which a few papilte are visible ; the uvula, 
the velum palati, and pharynx are of a bright red color, 
and the tonsils swollen and specked with a filmy de- 
posit, already described, which is generally closely ad- 
herent to the mucous membrane, although in some 
cases it is easily removed in its earlier stages by the 
application of the sponge probang, which is often 
coated with the new-formed deposits. 

" This membranous exudation may extend over the 
whole palate, but in mild cases rarely does ; nor is its 
color much deepened, or the odor emitted offensive or 
fetid. The submaxillary glands are slightly swollen, 



Description. 19 

but do not attain the size which they acquire in the 
severer forms of the disease. Under favorable cir- 
cumstances, or the application of judicious treatment, 
its progress is here arrested. The membrane ceases to 
spread, and slowly becomes detached from its connec- 
tions ; the mucous membrane loses its red color ; the 
glandular swellings subside ; the pulse diminishes in fre- 
quency, and the patient becomes decidedly convalescent. 
" The disease, however, does not always present 
itself in this form, but is ushered in by rigors and 
often vomiting, under whose influence the patient be- 
comes so prostrated, that it soon becomes obvious that 
the system is oppressed by a powerful poison. This 
condition is characterized by a high [violent?] fever, 
a pungent skin, a rapid and feeble pulse, great diffi- 
culty in deglutition, hurried respiration, flushed coun- 
tenance, and congested lips ; the tongue becomes loaded 
with a yellow or dirty brown coat ; the soft palate and 
pharynx assume a deep erysipelatous redness ; the 
tonsils become greatly swollen, and the ash-colored 
membrane, nearly continuous and spread over one or 
both tonsils, extends to the uvula and the posterior 
walls of the pharynx. As the disease advances, these 
symptoms increase in severity ; the breathing becomes 
more hurried and stertorous ; the swallowing, which at 
first was but moderately impeded, becomes so trouble- 
some and painful, that the child is with great difficulty 
induced to take either food or medicine ; the saliva 
flows from the mouth, and often a foul and acrid dis- 
charge from the nostrils. Should the little patient be 
induced to swallow, food or drink will be violently 
ejected, and a paroxysm of great intensity, in which 
the child will gasp for breath, and with great difficulty 
recover itself, will ensue. 



20 * DiPTHERIA. 

" The case has now reached a point which portends 
the most unfavorable results. The false membrane has 
seized upon every visible part of palate and pharynx ; 
the discharge of sanies mixed with blood, which issues 
from the mouth and nose, has become exceedingly 
offensive ; the glands of the neck become enlarged and 
tender, the voice hoarse and indistinct, the pulse more 
rapid and feeble, and the poor patient, restless and 
embarrassed for want of breath, tosses about or lies on 
his back in a semi-comatose state ; in most cases the 
medical attendant is apprised by a croupy respiration 
when the membrane has invaded the larynx and 
trachea, at which time symptoms of asphyxia present 
themselves ; the countenance becomes livid, the skin 
cold, the pulse feeble or gone, and the patient, either 
distressed for want of breath, anxiously awaits the 
moment when death shall relieve him of his sufferings, 
or rapidly sinks into an asthenic or comatose condi- 
tion." 

The careful reader will not fail to notice some dis- 
crepancies in the symptoms, as described by the various 
authors thus far and hereafter to be quoted, a fact 
which shows the great diversity of forms and the 
various degrees of malignancy under which the dis- 
ease appears in different persons. 

A. 0. Hamlin, M.D., Surgeon 2d Regiment Maine 
Volunteers, in an article published in the New York 
Medical Times of Feb. 22, 1862, makes the following 
remarks in relation to diptheria as it prevailed in his 
department of the army: " Since the commencement 
of the campaign, some thirty cases of diptheria have 
been observed by us, most of which have been so ob- 
scure and complicated as to render diagnosis perplex- 
ing, and often inclining us to doubt whether the malady 



Description. 21 

merited a distinction from some other phlegmasias of 
the throat by reason of functional symptoms and 
physical signs. Rarely did it commence with the 
pellicle of Bretonneau, though it afterward assumed 
many of the peculiarities of the disease in an ad- 
vanced stage. Sometimes the exudation appeared like 
cryptogamous vegetation ; then, again, there were 
ulcerated fissures or irregular patches with flake-like 
lymph. All the cases appeared during or after wet 
and stormy periods, when the atmospheric variations 
were sudden and the electric oscillations considerable. 
All ended in resolution, without serious injury to the 
system except one, in which instance death ensued from 
hemorrhage of the palatine or pharyngeal arteries. 
The enlargement of the cervical glands was often very 
great, with occasional abscess. The attending pyrexia 
[fever] and constitutional disturbance were in most 
cases slight." 

Dr. Fouregaspd, of Sacramento, California, thus de- 
scribes diptheria as it appeared in that place : 

"The disease begins in a very insidious manner, by 
a little engorgement or inflammation of the soft palate, 
pharynx, and one of the tonsils. At this period the 
patient complains but little — there is no fever, or it 
is very moderate. The pain in the throat is much 
slighter than in the usual forms of sore throat — so 
slight, that the little patients go about playing as if 
nothing was the matter. In some exceptional cases, 
the fever and inflammation about the pharynx are con- 
siderable from the beginning. The characteristic signs 
of the invasion soon follow. They consist in small 
portions of white or yellowish lymph deposited on the 
palate, the tonsils, and the posterior part of the pharynx. 
The cervical and submaxillary glands become swollen, 



22 DlPTHERIA. 

and the pain in swallowing and opening the mouth is 
occasioned more by the engorged state of the glands 
than by the internal secretion of lymph. These de- 
posits go on increasing in size more or less rapidly, 
and in violent cases in a few hours the whole cavity 
of the throat is covered by them. Generally one side 
is more affected than the other, and the glands corre- 
sponding with the parts affected are more swollen than 
those of the opposite side." 

Dr. Blake, of California, in the Pacific Medical and 
Surgical Journal, August, 1858, describes the access 
and progress of the disease : " Drowsiness, prostration, 
or oppression is manifested by infants, or complained 
of by adults ; and when the disease is prevailing, this 
desire of children to sleep at other than usual hours 
should awaken our suspicion. The pulse is accel- 
erated from the first, but generally soft and typhoid ; 
although in some cases it is for a few hours rather hard. 
The temperature of the skin is raised, although seldom 
harsh or dry ; and frequently moist, or even covered 
with profuse perspiration. There is seldom any pain ; 
rarely headache or backache. The tongue is usually 
coated, edges red, papillse prominent. The appetite 
may remain good, and the digestion unimpaired. If 
we examine the throat we may find, even within 
twelve hours after the occurrence of the first slight 
symptom, the tonsils covered with a gray, pultaceous 
exudation, which rapidly extends upward into the nos- 
trils, and downward toward the larynx ; and again, 
we may detect only a redness of the tonsils and a small 
point of exudation, two or three days after the com- 
mencement of the disease, and at a time when the 
symptoms of general prostration had become alarming. 
Again, cases may present themselves in which the 



Description. 23 

general symptoms and the anatomical lesions proceed 
pari passu ; but in almost every case that I have seen 
I have considered that death was the result rather of the 
action of the poison on the system than from obstruction 
of the larynx. In from twelve to twenty-four hours after 
the formation of the false membrane, we generally find 
the cervical glands enlarged, and in severe cases this 
enlargement may afford a serious obstacle to respira- 
tion and deglutition." 

Professor Alonzo Clark, M.D., of the New York 
College of Physicians and Surgeons, in his lectures 
on diptheria, as published in the New York Medical 
Times, distinguishes between epidemic sore throat, 
which has little tendency to the production of mem- 
brane, and true diptheria — the former being com- 
paratively a mild disease. The difference, however, 
may be more in degree than in kind. 

Dr. Clark, limiting the term, diptheria, to such forms 
of inflammation as terminate, or have in their course 
this membrane as a sign, thus describes the order of 
symptoms : 

" As to its initiatory symptoms, they have no definite 
relation to the future severity of the disease or to the 
parts that are to be the seat of the inflammatory exu- 
dation. When diptheria appeared among us for the 
first time as a prevailing disease, the cases that I saw 
w T ere almost all of them ushered in by pretty acute 
symptoms ; a chill, followed by a fever ; and then, in 
a small proportion of cases, a chill and fever alter- 
nating two or three times in the course of a single day. 
Those instances in which the chill was repeated were 
rare; but a very decided invasion was, in the cases 
that I saw, the rule in the beginning of the disease. 
As it went on, the symptoms of invasion were less and 



24 DlPTHERIA. 

less marked, and not unfrequently, as is now noticed, 
it occurs without any that attracted attention. Several 
instances of this kind now occur to my mind ; but two 
of these will serve for illustration : 

" Two children, two and a half and four years of 
age, were observed to have the symptoms of slight ca- 
tarrh for two or three days, but there was nothing to 
awaken anxiety. They followed their amusements in 
the nursery as usual, when at length the mother no- 
ticed a croupy cough in the youngest, and sent for the 
family physician. He found the usual early symptoms 
of croup, and a diptheritic membrane on the tonsils, 
extending downward beyond the reach of sight. He 
examined the other child's throat, not because he ex- 
pected to find any evidence of grave disease, but from 
motives of prudence, and was surprised to find the ton- 
sils almost completely covered with false membrane. 
The youngest grew rapidly worse, and in four days 
died of diptheritic croup. The eldest was at no time 
dangerously sick, and did not keep her bed a single 
day. The membrane was detached in two days, and 
did not reappear. The only medicines were tonics and 
chlorate of potassa, with full nutrition. Bretonneau, 
in examining the throats of young persons in a school 
where diptheria was prevailing, found the membrane 
in many instances where there was no complaint of ill 
health, and where it was not suspected till it was ac- 
tually found. Such cases will teach you two import- 
ant lessons : first, that the disease does not always 
make its invasion by any symptoms calculated to ex- 
cite alarm ; and secondly, that those symptoms, when 
once declared, are to be considered by no means as a 
measure of its severity. It is not easy, then, to fix iu 
very definite terms the character of the invasion, the 



Description. 25 

symptoms being sometimes very decided, at other 
times very insidious. But where the disease is once 
formed, you look for symptoms relating to the fauces, 
trachea, nasal passages, mouth, or esophagus, for it is 
in these that the membrane is most frequently formed. 

" When it is confined to the fauces, there is often 
but little occasion for alarm. These are the cases from 
which most of the recoveries come. The breathing is 
not interfered with; there is not necessarily much 
cough ; the general health may not suffer materially. 
And yet, let me say to you, that when it forms in the 
fauces only, and does not extend beyond, you will not 
unfrequently find, as the disease advances, the most 
formidable symptoms ; and as we shall see, by-and-by, 
too often a fatal result. 

" When it advances into the nasal passages, you will 
have indications somewhat before the formation of the 
membrane. You will usually see it in the fauces, 
perhaps folding back beyond your view upon the pal- 
ate ; the nose will become a little red, and there will 
be a little snuffling upon one or both sides ; directly 
there is a discharge of a yellowish watery or ichorous 
matter, nearly transparent. This may irritate the skin 
of the lip a little, and may, in the end, cause swelling 
of the upper lip itself. Soon after this discharge 
makes its appearance, there may be seen forming upon 
the swollen mucous surfaces a delicate membrane, and 
this, growing thicker and more abundant, will not un- 
frequently stand out upon the white tissues joining the 
red of the nose. And then still the ichorous matter 
will continue to be discharged; it will sometimes dry 
up on the false membrane, and finally plug up the nos- 
trils altogether, so that respiration can be performed 
only through the mouth. At other times the nostrils 

2 



26 DlPTHERIA. 

are not plugged up, and breathing through them is 
only difficult. 

" When the membrane forms in the esophagus, you 
have no very decided indications of its presence there. 
There is no great difficulty of swallowing ; there is no 
particular pain that will lead you to the suspicion of its 
formation in that tube. You learn it mainly from the 
fact that ribbons, or a large membrane, are vomited up, 
or perhaps the same things may be found in the stools. 

" But when the larynx and trachea are invaded, you 
have the most formidable variety of this disease. Then 
it is that you have everything to fear. Then the chances 
for recovery are scarcely so good as one in eight or ten 
of all who are attacked. The symptoms of this inva- 
sion of the trachea and larynx are precisely or almost 
precisely those of croup. The voice is changed ; it 
loses its compass and strength, and frequently is re- 
duced to a whisper. The breathing becomes noisy ; we 
call it stridulous ; the cough, for the most part, be- 
comes hoarse and croupy — occasionally shrill and 
brassy ; there is difficulty of breathing ; the child's 
head is thrown back to open the larynx fully and give 
force to some of the respiratory muscles. He not un- 
frequently vomits, but this affords him very little re- 
lief. The difficulty of breathing becomes more and 
more considerable as the disease increases, and in some 
instances there is very marked restlessness. In other 
instances there is much drowsiness. The surface of the 
body often shows the marks of incomplete aeration of 
the blood. The nails and lips become blue, or there 
may be a general cyanotic condition. The wings of 
the nose are expanded in inspiration. Everything 
shows that the child is about to die from asphyxia 
or apnoea. While in the other forms of the disease 



Description. 27 

children die from the general influences of the dip- 
theritic poison, these scarcely live long enough to ex- 
perience them. 

"This membrane may be found lining the whole 
mouth. Then it usually is produced first in the fauces, 
and extends forward. In my observation, the mouth 
does not take on this diseased action in the mild cases, 
but rather in those in which the disease is invading 
the nasal and respiratory passages. It has been known 
to begin on the gums (gingival diptheria), and extend 
backward into the fauces, so covering the mucous 
surfaces of the mouth. When the mouth is so cov- 
ered, the red tissues are everywhere — on the roof, the 
inner surface of the cheeks, the tongue, the gums — 
hidden by a layer of exudation that looks like a half- 
dried coating of plaster-of-Paris. As this peels off por- 
tion by portion, the natural structures are left red and 
shining. This stomatic diptheria alone is no more 
grave than other forms of the same disease, and much 
less so than the tracheal variety. It produces but little 
of actual pain, but it makes the mouth stiff and embar- 
rasses its motions ; destroys the taste for the time ; 
makes it painful to talk and swallow. Hot and stimu- 
lating drinks appear to be* in the highest degree un- 
pleasant. Indeed, the little sufferers affected in this 
way sometimes resist every administration by the 
mouth with a perseverance — I may even say a frenzy 
— which only an absolute and apparently cruel firm- 
ness on the part of attendants can overcome. 

"In all these forms of disease one feature is almost 
uniformly noticeable, and that is a swelling of the glands 
at the angle of the jaw, and of those extending down- 
ward from this point. Indeed, it is regarded as one of 
the diagnostic marks in the early stage that these 



28 DlPTHEEIA. 

glands, though ever so little, are swollen. They are 
usually swollen unequally. When the disease is pre- 
vailing, Bretonneau warns us, at the least snuffling, on 
the slightest indication of coryza, to feel behind the 
angle of the jaw, and below the lobe of the ear, and so 
down the side of the neck for swollen lymphatic 
glands. We are then to examine the upper lip. ' In 
simple coryza the skin is reddened equally under each 
nostril, while in the Egyptian disease it is only on the 
side of the glandular swelling. If the swelling exists 
on both sides, it is unequal. On the side where the 
swelling is least, the redness of the lip will be least. 
From the period of this discovery we are certain there 
is a special affection — in fact, the Egyptian disease. 5 
By ' Egyptian disease,' M, Bretonneau means dip- 
theria. 

"In this connection, I may better say that this dis- 
ease may appear on the gums, as it often appears on 
the tonsils, without extending beyond the parts it first 
attacks. Such cases belong, in general, to the milder 
forms of diptheria. 

" Among the rarer seats of diptheritic exudation, I 
may mention the external ear. This tube has been 
seen lined by it. M. Bretonneau reports an instance in 
which the lining membrane of the antrum highmoria- 
num was fully involved. A poor Jew had died while 
the physician was making preparations for tracheot- 
omy. The false membrane was found in all the air 
passages as far as they could be followed, and also 
making an adventitious lining of loth maxillary si- 
nuses, tilling both with a turbid serous fluid, in which 
were floating bands of false membrane, as in a pleu- 
ritic effusion. 

" 1 have here a letter from Dr. Whittlesey, physician 



Description. 29 

to the Children's Hospital on Randall's Island, relating 
to some cases of diptheritic ophthalmia that occurred 
there some time ago. Dr. Hives, assistant physician in 
that institution, two or three years ago, exhibited to me 
some specimens of this disease, and they were shown to 
the class then attending lectures here. The eyelids were 
both covered by a firm, elastic exudation, and the same 
membrane covered the conjunctiva of the eye as far as 
the cornea. Dr. Rives informed me that in his depart- 
ment of the hospital there had been at that time five 
cases of this affection, more or less extensive, and that 
in his cases, if the patient survived, the inflammation 
was destructive to the eye, and blindness followed. 
Dr. Whittlesey's letter informs me that these cases oc- 
curred in the winter of 1857 and '8, before diptheria 
became epidemic in this city, and while it was pre- 
vailing in Albany. But a similar disease showed 
itself in that institution four years earlier. Dr. "Whit- 
tlesey states that, ' In the winter of 1853-4 measles and 
scarlet fever prevailed in this institution, and there 
were three cases of diptheria. The patients were chil- 
dren that had suffered from measles, and were in a 
feeble, emaciated condition. They all died in a few 
days after the membranous disease appeared. The 
deposit or exudation was upon the inside of both eye- 
lids, nearly a line in thickness on the upper, and of 
such consistence that it could be removed with forceps, 
retaining the form of the lid as a cast, presenting an 
appearance similar to that of the specimen presented 
to you by Dr. Rives.' This form of diptheria has been 
repeatedly noticed in Europe. 

" These are, however, only the local manifestations. 
Those of a more general character are still to be con- 
sidered. It not unfrequently happens that persons who 



30 DlPTHERIA. 

have gone through with all that I have now described 
to you, and appear to be recovering, suffer still from a 
prostration that seems almost unaccountable. Take 
one or two fatal examples. Early in the occurrence of 
the epidemic, in a patient of Dr. Crane's, the membrane, 
if I remember rightly, was found, as it is commonly, 
in the fauces, but not beyond. The patient went 
through with the earlier stages of the disease, the 
membrane exfoliated, and everything seemed to be 
doing well. His convalescence was announced to the 
friends of the family. About ten days after the mem- 
brane disappeared, Dr. Crane was called in haste to 
see the child, as it was very much worse. When he 
reached the house, he found that he was so much 
prostrated that there was scarcely any pulse. The 
patient had been sitting up the earlier part of the day, 
but now he could not raise his head from the pillow 
without fainting. It seemed to the Doctor that there 
was internal hemorrhage, yet there was no other mani- 
festation of it. In this sinking condition the little one 
remained from two in the afternoon until seven in the 
evening, when he died, precisely, if I can judge, as 
persons usually die from the rupture of some vessel 
that allows fatal hemorrhage into the intestines or 
uterus. On the morning of the day on which he died, 
there was nothing to lead to the suspicion that he 
would not get well, except the treacherous nature of 
the disease. In Dr. McCready's case, already referred 
to, a similar history is to be given. This child had an 
extraordinarily thick membrane formed upon the tonsils 
and uvula ; you see a portion of it in that vial. The 
symptoms were those of ordinary sore throat at first. 
In a day or two the tonsils became covered with the 
membrane. There was not much disturbance of the 



Description. 31 

general health.. In a few days exfoliation took place, 
and there was promise of speedy recovery. A week 
later, however, membrane appeared in. nostrils ; rapid 
collapse followed, and the child died in twenty-four 
hours. 

" A son of Mr. D., two years old, had the diptheritic 
membrane first in the fauces, afterward in the larynx, 
and probably in the trachea. Little hope was enter- 
tained of his recovery for many days. At length the 
croupous cough, the rapid and stridulous breathing 
slowly subsided, with the expectoration of fragments 
of membranous matter, and the child appeared to be 
convalescent. The danger seemed to have passed, and 
he was taken into the country. But there he lost 
strength and flesh, sank into deep prostration, and died 
in three weeks without renewal of the dyspnoea, or any 
other symptom of throat disease. 

" Well, now, what is it that produced death under 
these circumstances ? The obvious answer is — a certain 
poison, the nature of which we do not understand, 
which, though it has spent its force to produce local 
manifestations, has not yet exhausted its fatal control 
over the nervous system. It seems to destroy, making 
allowance for the difference in time, as prussic acid 
does, by overwhelming the nervous forces. I know 
nothing else to say about it. A case or two more to 
illustrate this point. In a patient on Staten Island, 
whom I saw with Dr. Gunn, the history is a little 
different, and yet no more favorable. A young lady, 
fourteen years of age, had the membranous disease of 
the fauces ; it was of the variety once called the 
sloughing sore throat. A membrane had formed of 
considerable firmness and thickness, and apparently in 
successive layers ; the older parts were sloughing off 



32 DlPTHERIA. 

from the newer. Her throat looked as if there was 
an abundant dirty purulent slough covering it. This 
is no uncommon appearance ; and these very appear- 
ances have led to some of the names which have been 
given to this membrane in the older time. You can 
hardly believe when you see such an appearance that 
it is not really a gangrenous condition of the natural 
tissues of the parts ; but if you watch such a case, and 
it has a favorable termination, you will see that the 
whole of this material will clear off without even so 
much as a depression being left. This was the condi- 
tion of the young lady's throat. Her breath was 
somewhat, but not markedly fetid, She had been 
sick just six days, when I saw her. She had been 
attacked with sore throat pretty suddenly in church. 
Not having a chilly feeling, but still experiencing gen- 
eral discomfort, she left the church for her father's 
house. The physician was called the next day, and 
found the membrane. It continued then, from Monday 
until Saturday; and now, without any great loss of 
strength, without any difficulty in breathing, without 
any membranous formation of the nares, without any 
evidence even that it had formed in the esophagus, 
this young woman was about to die. At two o'clock 
in the afternoon of the Saturday her mind was per- 
fectly clear, her strength such that she had to be ad- 
monished not to use it. When it was proposed to do 
anything, to look at her throat, for example, she would 
jump to sit up in bed. This, of course, we forbade. 
There was a hlueness over the whole surface of the 
body, and yet the pulse was not very feeble. Her 
pulse did not give warning of what was to come in 
live hours, and yet in that time she was dead. She 
did not die of dyspnoea. She did not die of the direct 



Description. 33 

effects of inflammation in her throat, but of diptheritic 
poison, operating in some way or another apparently 
to prevent the free aeration of the blood, and how that 
could be I do not know — perhaps by some paralyzing 
influence on the pneumogastric nerve. 

" A beautiful girl, four or five years of age, had an 
exudation on her tonsils which was at first treated by 
repeated application of a strong solution of nitrate 
of silver; afterward by milder local applications, as 
chlorate of potassa. She had but little fever, and 
maintained, for the most part, a fair appetite. She 
was most of the time cheerful and playful, though 
almost wholly kept in bed as a measure of prudence. 
The membrane forming in successive layers on the 
tonsils, lasted twenty days, as I have said, without ex- 
tending to the air-passages or the nostrils. From the 
sixteenth day, she lost her relish for food. On the 
eighteenth, the pulse began gradually to increase in 
frequency without heat of skin, and without any dis- 
coverable cause advancing from eighty-five in the 
minute to ninety-five, one hundred, one hundred and 
ten. The next day it increased still in frequency to 
one hundred and twenty, to one hundred and thirty, 
and one hundred and forty; and on the third day of 
this acceleration, she died as the fire dies out for want 
of fuel. There was not the slightest dyspnoea from 
first to last — no hoarse cough. There was no visible 
hemorrhage." 

0. C. Tower, M.D., of South Weymouth, Mass., in 
the Boston Medical and Surgical Journal, March 7, 
1861, thus describes the disease as it prevailed in his 
immediate vicinity, amounting in all to seventy cases 
and sixteen deaths : " The patient generally feels some- 
what unwell for a day or two before the affection of 

2* 



34 DlPTHERIA. 

the throat is manifest. His appetite fails. Perhaps 
nausea and vomiting are the first symptoms. Adults 
complain of chilliness and aches in their limbs. If a 
child, he loses his inclination to play, and is inclined 
to be drowsy. There may be restlessness at night, 
gritting of the teeth, and feverishness. Not unfre- 
quently none of these precursory signs appear, and if 
any of them occur, they are not thought of at the time, 
but are recalled to mind by the patient, or the parents 
of the child, after the more patent symptoms set in. 
On the second or third day, if not before, there is ob- 
served some difficulty in deglutition, and externally 
may be felt slight enlargement of one or both sub- 
maxillary glands, which are tender on pressure. Per- 
haps the first thing noticed by the parents of the child 
is the swelling of the areolar tissue of the throat. At 
this period, examination of the fauces generally reveals 
swelling of one or both of the tonsils and soft palate, 
accompanied with unusual redness of the mucous 
membrane. Small patches of membranous lymph, of 
a dirty-whitish color, are also visible. I have detected 
this deposit when it w r as no larger in extent than a 
split pea, but usually it is as large as a three-cent 
piece. I have been first called to attend a patient 
when the whole fauces and soft palate w-ere covered 
with this exudation. Parts of the pharynx not cov- 
ered with this false membrane are usually edematous 
and fiery red, resembling erysipelas. 

u From this period the symptoms rapidly increase in 
severity, if not arrested. At the expiration of a week 
the prognosis, whether favorable or otherwise, can be 
determined. Death usually occurs between the end 
of the first and second week. 

" The swelling of the throat in severe cases is very 



Description. 35 

great, so as to interfere with the venous circulation, 
thus producing a bloated and dusky aspect of the 
countenance. Breathing becomes laborious, causing 
the head to be thrown backward. The skin is moist, 
often bathed in perspiration. The pulse is rapid, soft, 
and small. Speech becomes lost, or audible only in 
whisper. The strength rapidly fails. Expectoration, 
at the end of a week, is quite profuse. Large flakes 
of fibrine, perfect castings of the air-passages, may be 
expelled by coughing. 

" There is an odor, characteristic of this throat affec- 
tion, sometimes so intense as to pervade the whole 
apartment. 

" Death usually occurs from exhaustion of the vital 
forces. Frequently the little patient lies several hours 
in a half comatose state before life ceases. There is 
much suffering from dyspnoea in severe cases, when 
symptoms of croup manifest themselves. 

" Starting at the pharynx, this disease extends up- 
ward into the nasal openings of the frontal sinuses, 
backward into the eustachian tubes, and downward 
into the trachea and bronchi, and, as I have reason to 
believe, into the alimentary tract." 

Professor George B. Wood, M.D., of Philadelphia 
(Wood's Practice of Medicine), who treats of diptheria 
under the name of pseudo-membranous inflammation 
of the fauces, has very well collated and arranged the 
symptoms, as they are manifested in the great majority 
of cases : u The disease commences with some redness 
of the fauces and uneasiness, such as occur in ordinary 
sore throat, but usually in a less degree. This condi- 
tion lasts but a very short time before the exudation 
commences ; and, when first seen by the physician, the 
surface almost always exhibits small, irregularly cir- 



36 DlPTHERIA. 

cumscribed, whitish, yellowish-white, or ash-colored 
patches, sometimes seated in a portion only in the 
fauces, sometimes scattered here and there over almost 
their whole extent. These patches bear no inconsider- 
able resemblance to superficial sloughs, or to the sur- 
face of ulcers, for both of which they have not unfre- 
quently been mistaken ; but it has been shown, by the 
most careful microscopic observations, that they consist 
of a concrete exudation similar to false membrane, and 
that the surface of the membrane beneath them has 
not necessarily undergone any loss of substance, unless 
of the epithelium. Sometimes, however, ulceration is 
found to have taken place beneath them. In some 
instances the patches are translucent. Their consist- 
ence is various, occasionally pultaceous, but more fre- 
quently somewhat dense and even tough. The mem- 
brane around them is inflamed and reddened, and the 
tonsils are usually more or less swollen, as are fre- 
quently also the cervical and submaxillary glands, and 
sometimes even the parotids. Examined by the micro- 
scope, they have been found to consist mainly of 
interlacing fibrils, with molecular granules, epithelial 
cells in different stages, and often pus or blood cor- 
puscles. 

" In mild cases, such as often occur sporadically, the 
patches are few, more regularly circumscribed than in 
the severer forms, and not disposed to spread ; while 
there is little tumefaction either of the tonsils or the 
external parts, and little or no fever. They are apt, 
however, to be attended with much pain in swallowing. 
In the severer cases, the patches spread with greater 
or less rapidity, sometimes in the course of a few 
hours coalescing and covering the whole fauces, but 
more frequently advancing rather slowly, and leaving 



Description. 37 

portions of the membrane uncovered. There is com- 
monly more of the exudation on one side than on the 
other ; and on that where it is more abundant the 
swelling of the tonsils and external parts is greatest. 
The deglutition now becomes more difficult, and 
liquids often return by the nostrils in attempts to 
swallow. The patches, soon after they are completely 
formed, begin to be removed, sometimes separating in 
strips, sometimes softening and mixing with the fluids 
of the mouth, and in a few cases disappearing by 
absorption. They are often renewed, occasionally 
several times, each time becoming whiter and thinner, 
till at length they leave the surface covered with a 
puriform mucus. The process of separation usually 
lasts eight or ten days. (Guemset.) During its pro- 
gress, it is attended with the discharge of .some blood 
and copious vitiated secretions, w r hich occasion much 
hawking and spitting, and hence a very offensive odor. 
There is often also a flow of extremely fetid sanies 
from the nostrils, indicating the extension of the disease 
to the nasal passages. The odor of the discharges in 
these cases has tended to confirm the erroneous idea 
that the disease is essentially gangrenous. In the 
course of the complaint, the disposition to exudation 
often travels downward, and the larynx, trachea, and 
even bronchia become lined w T ith false membrane, 
which obstructs respiration, and often leads to fatal 
results. This extension of the disease constitutes, in- 
deed, its chief danger. It may come on at any period, 
from the first appearance of the patches to the seventh 
or eighth day, and is indicated by those changes in the 
voice and respiration which characterize pseudo-mem- 
branous croup. A distinguishing characteristic of this 
diptheritic affection, showing that it is connected with 



38 DlPTHEElA. 

the state of the system at large, or of the blood, is 
that it is disposed to appear on most other surfaces 
which may be excoriated or suppurating. The mu- 
cous membranes to which the air has access, and the 
skin, are peculiarly liable to be affected; but the mu- 
cous lining of the stomach and bowels is remarkably 
exempt." 

PATHOLOGY OF DIPTHERIA. 

I employ the phrase, pathology of diptheria, in def- 
erence to " established usage," rather than in obedience 
to scientific propriety. The "pathology of disease," 
though an expression very frequently occurring in 
medical literature, is as nonsensical, considered in the 
light of true science, as is another technicality quite as 
commonly found in the medical phraseology of the 
day, to wit, the " physiological effects of medicines." 
When it is considered that medicines are confessedly, 
in their relations to the vital organism, absolute poi- 
sons, the absurdity of the word " physiological" is 
sufficiently manifest. And when it is understood that 
disease is pathology and pathology is disease, the 
pathology of disease must be regarded as something 
akin to a " rhetorical flourish" or a u glittering gen- 
erality." 

But medical technology must of necessity be in har- 
mony with the doctrines on which it is predicated ; 
and if these are false, the nomenclature of the so-called 
science can be nothing more nor less than technical 
gibberish — the " incoherent expressions of incoherent 
ideas." 

And now it so happens that the medical profession 
does entertain and teach — as I have shown in other 
works — a false doctrine of the nature of disease; a 



Pathology. 39 

false doctrine of the action of medicines ; a false theory 
of vitality ; a false doctrine of the law of cure ; a false 
doctrine of the relations of remedies to diseases ; a false 
doctrine of the relations of remedies to the living or- 
ganism ; a false doctrine of the relations of disease to 
the living system ; and a false theory of the vis medi- 
catrix naturae / and these facts necessitate a false 
technology. 

The term pathology, when applied to disease, should 
be superseded by the word nosology, as this means the 
classification and arrangement of disease — the relation, 
so far as morbid conditions and actions are concerned, 
of one disease to another. If one should employ the 
term diseaseology, or the phrase, the disease of disease, 
or the pathology of pathology, he would be accused 
of misusing language very nonsensically ; yet these 
phrases are not a whit more absurd — not to say ridicu- 
lous — than are one half of the technicalities to be found 
in medical books. 

A good illustration of this subject is found in the 
writings on materia medica and therapeutics. For ex- 
ample, Pereira, in his elaborate work (Materia Medica 
and Therapeutics), under the head of the Physiological 
Effects of Corrosive Sublimate, says : " When growing 
plants are immersed in a solution of this salt, a part 
of the poison is absorbed, a change of color takes place 
in the leaves and stem, and death is produced" Is 
not death a queer " physiological" result ? I venture 
the opinion that no man alive, whose reasoning powers 
in relation to medical subjects had never been twisted, 
distorted, perverted, subverted, introverted, and retro- 
verted by a medical education, would ever suspect this 
result to be physiological ! He would certainly judge 
it to be just the contrary — morbid, pathological. 



40 DlPTHERIA. 

Pereira says further : " On dogs, cats, horses, rabbits, 
and frogs, experiments have been tried with bi-chlo- 
ride of mercury,- and it has been found to exercise a 
poisonous operation." And so its " physiological 
effects" are incomprehensible on animals as on plants. 
It simply poisons them to sickness or death, and this is 
exactly the opposite of any thing or process to which the 
word physiology can be properly applied. 

But how is it with man ? Pereira says : " Corrosive 
sublimate causes, when swallowed, corrosion of the 
stomach ; and in whatever way it obtains entrance 
into the body, irritation of that organ and of the rec- 
tum, inflammation of the lungs, depressed action, and 
perhaps also inflammation of the heart, oppression of 
the functions of the brain, and inflammation of the 
salivary glands." 

If this be physiological, physiology is a different 
thing from what the dictionaries define it to be. It is 
there called the " science of life." But medical au- 
thors would have it the process of death. It is there 
explained to be the doctrine of the normal actions. But 
our medical books make it the doctrine of abnormal 
conditions. 

Physiology comprehends simply and solely the vital 
functions in their normal exercise, as manifested in the 
nutrition, development, and growth of the body ; but 
medical men misapply the term to its morbid pro- 
cesses, and so confound all distinctions between food 
and poisons, between health and disease, between nor- 
mal function and remedial effect, between the vis con- 
servatrix natures and the vis medicatrix naturae — in a 
word, between physiology and pathology. 

Dunglison tells us in his Medical Dictionary that 
pathology has been defined the physiology of disease. 



Pathology. 41 

Now, disease has no physiology. It is the very oppo- 
site of physiology. It is pathological from first to 
last. It is disease ! The term, " disordered physiol- 
ogy," as employed by Dr. Good (Study of Medicine), 
is appropriate, for it means, simply, abnormal or mor- 
bid action, and this is pathology, disease. It is quite 
as absurd to apply the term physiological to diseases 
and poisons as it would be to apply the term patho- 
logical to food and health. 

What is diptheria? Medical writers agree that it is 
an inflammation, or a fever, or both ! But what is in- 
flammation or fever ? This problem the profession has 
not yet solved. It professes to understand only the 
forms and features, the phenomena of inflammation 
and fever ; but of their real character or essential nature 
it teaches, and books confess that they know, nothing. 
And why should they, so long as they can not explain 
what disease itself is ? 

Says Professor Gross : " Of the essence of disease we 
know very little ; indeed, nothing at all." The con- 
clusion follows by irresistible logic that, if the medical 
profession can not understand the nature of disease as 
such — if it knows not what disease is, it can not. in the 
very nature of things understand the nature of any 
particular form of disease ; ergo, the profession knows 
nothing of the essential nature of diptheria, and this 
may account for its unsuccessful treatment of the 
malady. 

The relation of diptheria to croup and to. malignant 
scarlet fever has been much discussed through the 
medical journals, some authors regarding diptheria as 
identical with that form of scarlatina in which the ex- 
cretion of morbid matter is mainly determined to the 
throat, with little or no cutaneous eruption, while 



42 DlPTHEEIA. 

others regard it as differing from croup only in the 
fact that the inflammatory action affects principally the 
mucous membrane of the throat, instead of that of the 
trachea or windpipe, as in the case of croup. 

Whatever may be true in theory, the facts are suf- 
ficiently obvious. It is true that in the cases of mem- 
branific inflammation, to which the term diptheria is 
usually applied, there is an exudation of fibrinous 
material — coagulable lymph — on the mucous surface 
of the throat, quite analogous and frequently identical 
in character with that which takes place on the mu- 
cous surface of the trachea in croup ; and in some 
cases extending, as w T e have seen, into the windpipe 
and esophagus. It is also true that scarlatina malig- 
na is characterized by ulcerative inflammation of the 
throat, instead of the exudation which produces the false 
membrane. And it is equally true, moreover, that in 
some cases of diptheria ulceration does take place 
beneath the membranous formation, while in some 
cases of putrid sore throat there are patches, more or 
less extensive, of diptheritic or croupal excretion. 
For all practical purposes, therefore, we may regard 
diptheria as combining the morbid conditions of both 
croup and malignant scarlet fever, one or the other 
being more prominent according to the condition and 
habits of the patient in whom the disease occurs. 

There is much discrepancy among the authors as to 
the symptoms of diptheria which are supposed to 
identify it with croup on the one hand, or malignaut 
scarlatina on the other. Some authors have noticed a 
scarlet eruption of the skin accompanying the throat- 
affection, and the putrescent condition of the whole 
system, attended with fetid breath and foul excretions, 
as in malignant scarlet fever ; while other authors de- 



Pathology. 43 

scribe it as being entirely free of offensiveness and 
eruption. 

Both sets of authors are correct in their facts, yet 
mistaken in their theories. The disease occurs in per- 
sons of very different dietetic and other personal 
habits, and in very different conditions of system, so 
far as grossness of blood and exhaustion of vital 
power are concerned. These facts, which are of the 
utmost importance in enabling us to understand the 
rationale of the various forms of diptheria, seem to be 
wholly overlooked and unthought of by the authors 
who have written on the subject. 

Every febrile disease of the continued type — and 
diptheria is a continued febrile disease ; that is to say, 
a local inflammation essentially accompanied with a 
constitutional fever — is either of the inflammatory or 
typhoid diathesis ; and if of the typhoid diathesis it is 
either of the putrid or nervous form. Diptheria is 
always of the atonic, low, or typhoid diathesis ; and 
never attended with high or entonic fever. And if the 
condition of the patient be very gross, the disease will 
present the putrid phase of fever, usually called 
typhus, or typhus gravior in medical books ; but if 
the patient be in a less gross and more debilitated 
state, the disease will be of the nervous form, the 
typhus mitior of the older authors, the typhoid fever 
of modern authors, and the enteric fever of Wood and 
others. 

But our medical authors are wholly at fault as to 
the causes of these distinctions. They are usually at- 
tributed to some specific property in the morbific ma- 
terial which induces the malady, or to some quality 
inherent in the disease itself, as though this were a 
thing or entity outside of the living organism and 



44 DlPTHEBlA. 

capable of assuming a variety of shapes, whereas the 
real cause is to be found solely in the condition of the 
patient. In some places, where nearly every case of 
diptheria has terminated fatally, the disease is said to 
have been of a very malignant type ; and in other 
places, where few deaths have occurred, it is said to 
have been of a very mild type ; as though the disease 
had an existence and a character before it " attacked" 
the living organism. 

Such is the medical science of the nineteenth cen- 
tury, but it is a delusion. The disease, so far from 
existing as an entity outside and independent of the 
living system, so far from being a thing acting on or 
attacking the system from without, is really, as is 
every other form of disease, the action of the vital 
organism itself. It is the living system in the act of 
expelling impurities — a process of purification. And 
malignancy is determined, both in nature and degree, 
by the condition of the system, and always exists in 
the exact ratio to the grossness or putrescency of the 
blood, or the debility or exhaustion of the nerves. 
When diptheria, therefore, occurs in persons of so 
gross and putrescent a condition of blood as to induce 
the putrid form of fever, the breath of the patient may 
be very fetid, and the discharges very offensive, and 
the odor of the patient's room very disagreeable; 
while, if the disease occurs in persons of a feeble but 
not gross condition, although it may be equally malig- 
nant and equally fatal, it will have none of the pecu- 
liar evidences of putrescency of the fluids which 
characterize the other form. 

Diptheria, putrid sore throat, and croup, though 
usually distinct in diagnosis, may run into each other, 
as it were, by such imperceptible gradations that it is 



Pathology. 45 

sometimes difficult to draw the line of demarkation 
and tell where one ends and the other begins, dip- 
theria holding the intermediate relation, and combining 
in itself more or less, in different cases, the conditions 
of exudation and ulceration ; while croup and putrid 
sore throat represent, more distinctly, the membranous 
and the ulcerous forms of inflammation, as it is pre- 
sented in a low atonic or putrescent state of the 
system. 

Some authors have seemed to confound diptheria 
with quinsy — tonsillitis ; but in the latter case the 
swelling and redness of the tonsils, with difficult 
deglutition at the outset, and the absence of all evi- 
dences of fibrinous exudation, are sufficient to enable 
the careful observer to distinguish between them. 

Authors have disagreed also respecting the febrile 
or non-febrile character of diptheria ; and we are 
gravely assured by some authors who profess to have 
had much experience, that it is scarcely ever febrile ; 
while other authors as gravely talk of the disease 
" becoming typhoid," or of " typhoid symptoms super- 
vening." The truth is, the disease is always febrile, 
as are all acute visceral inflammations, although, in 
many cases, as in all visceral inflammation of low 
diathesis, the hot stage of the febrile paroxysm may be 
very slight and scarcely observed at all, or entirely 
overlooked. And the fever is always typhoid from 
first to last, so that the phrases " running into typhoid," 
" typhoid supervening," etc., indicate an erroneous 
view of the character of the malady. 

The following article appeared not long since in the 
New York Commercial Advertiser, and it represents 
very well many errors, both in pathology and thera- 
peutics, which are entertained by the great majority 



46 DlPTHERIA. 

of the medical profession. I copy it for the oppor- 
tunity it affords for corrective criticism. 

" This disease, though in many respects resembling 
croup — and in certain others, quinsy — is distinguish- 
able from both by certain well-marked characteristics. 
Like croup, it is accompanied by the formation of a 
false membrane in the windpipe, which, if left to itself, 
accumulates till the air-passage is closed and death 
ensues. But the false membrane of croup is an 
exudation of natural lymph from the vessels of the 
mucous membrane stimulated to excess by high febrile 
condition of the tissue ; while, on the other hand, 
diptheria is scarcely ever febrile in its pathology — and 
its pseudo-membrane is the result of a sloughing off 
rather than an exudation of the mucous coating. 
Croup belongs to the inflammatory type of diseases — 
diptheria, save in exceptional cases, does not. In 
croup, the breath of the patient is usually untainted. 
In diptheria, the breath is characterized by a peculiar 
and sometimes almost intolerable fetor. The lymphatic 
discharges of croup are seldom acrid. The discharges 
from the nose and mouth of a diptheritic patient are 
ichorous and excoriating to the highest degree. Croup 
is not particularly prostrating to the general strength 
of the person attacked by it. Diptheria is invariably 
accompanied by extreme debility, and a loss of mus- 
cular as well as nervous tone, which often continues 
for months after the immediately dangerous symptoms 
have been overcome. Finally, diptheria is contagious 
— croup is not. 

" It will be seen from these details that diptheria and 
quinsy have more intimate points of resemblance than 
diptheria and croup. In certain cases this resemblance 
is greatly increased by a complication of the pseudo- 



Pathology. 47 

membranous symptom of diptheria with malignant 
inflammation of the tonsils. Still the pseudo-mem- 
branous symptom is of course always sufficient to dis- 
tinguish it from quinsy. 

" It is not probable that diptheria is a new disease. 
The scientific accuracy of medical terms has made such 
rapid progress during the last half century, that the phy- 
sicians frequently find the data of diseases, as reported 
thirty years ago, unavailable through vagueness for 
the purposes of an indicative experience. Neverthe- 
less, from all that can be ascertained on the subject, 
the identity of diptheria with the " putrid sore throat," 
which made such fearful ravages in Albany and other 
places a quarter of a century ago, seems very probable. 
That malady was characterized by marked typhoid 
symptoms, and this indication has its counterpart in 
the extreme prostration of diptheria. If we recollect 
rightly, not a single case of the old putrid sore throat, 
which received the then universal depleting treatment 
of calomel and blood-letting, ever recovered from the 
disease. At the present day, nobody in his senses 
would think of letting blood or giving exhaustive med- 
icine for diptheria. 

" The treatment of the disease proposes to itself two 
ends : 

" 1st. To evoke and sustain all the natural vital 
forces of the patient. 

" 2d. To rid the air-passages of the false membrane. 

" For the attainment of the first end, nutritious, 
digestible food, being the most natural, is, of course, 
also the best means. Strong beef tea combines all 
the most desirable elements for such a purpose. It 
should be given from the earliest stages of the disease ; 
and when, as sometimes happens, the fauces become 



48 DlPTHERIA. 

closed by the disease, or the parts become too painful 
to admit of swallowing, it is still to be given in the 
form of anal injections. Brandy, in judicious hands, 
is another stimulus of the highest value in diptheria. 
Iron in various forms has been administered with 
great success. Perhaps its most efficient form, as 
determined by late experience, is the sesquioxide. Its 
effect seems to be two-fold— sustaining the general 
strength of the patient, and assisting the tendency of the 
mucous membrane to throw off and eject the diptheritic 
slough. 

" For the attainment of the second end innumerable 
methods have been proposed, and some of them have 
been very successful. Occasionally the use of the 
sesquioxide above mentioned has been successful, in 
co-operation with the forces of Nature, to produce the 
rejection of the membrane as fast as it accumulated 
and before it was indurated sufficiently to exclude all 
air from the lungs Sometimes it has been found 
possible to detach and pull out the membrane by 
means of a hooked or forcep-shaped instrument, though 
this operation has been known to result in dangerous 
hemorrhage. But by far the most successful treat- 
ment for relieving the diptheritic patient of the false 
membrane is that recently discovered by Dr. Lewis 
A. Sayre, of this city. His method is one of those 
admirable attainments of the highest class of inventive 
genius which, from their extreme simplicity and 
obviousness, awaken in every mind the remark — 
'Why, I might have thought of that myself! 5 Yet 
nobody ever does think of it till the inventive genius 
happens to show him the way. 

" The method of Dr. Sayre w r as the result of the fol- 
lowing observation. He noticed that if the discharge 



Pathology. 49 

of diptheria was expectorated upon any dry and warm 
substance — such as the side of a stove, for instance — 
it immediately became a tough pellicle, like a shred 
of gold-beaters' skin. But if the expectoration fell into 
a vessel containing warm water, it remained liquid and 
limpid, like ordinary thin lymph or mucus. 

" It now occurred to Dr* Sayre, that if from the first 
stages of the formation of the false membrane a hot 
and humid atmosphere could be kept in contact with 
it, it would remain as soluble as in this last-mentioned 
case, and be easily ejected through the nose and mouth 
like common mucus. 

" Several means of procuring this contact suggest 
themselves. The well-known plan of inhalation from 
the spout of a tea-kettle, and the ordinary vapor-bath, 
are among these. But the former is evidently imprac- 
ticable with those young children who are the most 
frequent sufferers from diptheria. They can not be 
made to keep their mouths in position over the narrow 
steam surface of a kettle. The vapor-bath is relaxing 
to the general system, and can not be thought of in a 
case which, like diptheria, requires every tonic and 
stimulant that can be made available. Moreover, it 
would be manifestly impossible to continue the patient 
in a vapor-bath through a period as long as the mem- 
brane is accumulating. 

"Dr. Sayre finally adopted this method. Having 
put the patient in a tightly shut room, he had aflat-iron 
heated to as near the white heat as possible. He sus- 
pended it over a pail in the sick-room, and kept the 
attendants pouring water on it till it ceased to evapo- 
rate every drop that came in contact with it. As soon 
as the iron was cooled down to such a degree that any 
surplus of water remained unevaporized, he replaced 

3 



50 DlPTHERIA. 

it with one freshly heated. He thus kept the room as 
full of steam as was consistent with comfortable 
breathing — at a temperature of 80° F. This process 
was continued for several hours ; during which not 
only the freshly sloughed membrane was constantly 
being expelled in liquid form through the nose and 
mouth, but membrane previously indurated in the 
trachea became soluble and was ejected in like man- 
ner. Meanwhile he kept up the strength of the 
patient by the above referred to means of beef and 
brandy. 

" The result of this treatment was an entire expul- 
sion of the slough, and, eventually, the complete cure 
of a case which had previously been abandoned as 
too desperate for even the dernier operation of tra- 
cheotomy. 

"Undoubtedly the means of evaporation for this 
purpose will hereafter be simplified by the discovery 
of the method. He has plans at present under con- 
sideration by which the process may go on independ- 
ently of the laborious and sometimes unreliable co- 
operation of attendants. Still, it is now a fixed fact 
that we have made the great and conclusive step 
toward a certain cure of diptheria. Also, that we 
owe that fixed fact to Dr. Say re. 

" The utmost care of the patient for weeks after the 
immediately dangerous symptoms have disappeared, is 
necessary to prevent a subsidence into the diptheritic 
state. Even where there is no return of the sloughing 
tendency, the general prostration of the system is usu- 
ally so extreme, that the most nourishing tonics and 
stimulant treatment are called for to ward off a natural- 
ly supervening attack of typhoid or low nervous fever, 
rapid decline, or chronic debility. There is perhaps 



Pathology. 51 

no form of disease known to the children's practi- 
tioner in which skillful hygiene and home-treatment 
are more imperatively demanded to follow up and per- 
petuate the results of medical effort. If possible, the 
greatest care must also be taken during the period of 
fetid discharges to separate the remaining children of 
a family from the diseased one, for, as we have above 
observed, this stage of the disease is quite infectious. 

"We notice that diptheria is again beginning to man- 
ifest itself as an epidemic in some of the rural districts 
of New York and the neighboring States. The words 
we have said may be of still more use in a city like 
ours, where life is so closely packed, infection and 
death so easy. But of these latter evils there is no 
need. Cure is now measurably simplified—prevention 
simpler still."* 

" Diptheria is scarcely ever febrile in its pathology." 
On the contrary, diptheria is always febrile in its 
pathology. " Croup belongs to the inflammatory type 
of diseases ; diptheria, save in exceptional cases, does 
not." Both croup and diptheria are always inflamma- 
tory and always febrile, each disease consisting essen- 
tially in a local inflammation and a constitutional 
fever. So far as inflammatory type is concerned, the 
word is misapplied. Type, when properly employed, 
pertains to the periodicity of the febrile paroxysms, as 
the continued remittent and intermittent types of fever, 
and not to the entonic or atonic diathesis which char- 
acterizes them, nor to the inflammatory or non-inflam- 
matory nature of a disease. The terms type and 
diathesis are employed quite promiscuously by modern 
medical writers, as are, indeed, a hundred other tech- 

* In the above article are many errors, both theoretical and prac- 
tical. 



52 DlPTHERIA. 

nical words and phrases, but it is for want of clear 
and correct ideas. 

The breath and discharges are generally more or less 
fetid and acrid in diptheria, as already remarked, ac- 
cording to the greater or less grossness or putrescency 
of the patient ; but in some cases which I have seen, 
these symptoms were entirely wanting, while there are 
cases of true croup in which the excretions are foul 
and offensive. 

" Croup is not particularly prostrating to the general 
strength of the person attacked by it." Such language 
indicates the false notion which the medical profession 
entertains of the nature of disease — an error which I 
have been combating in books and in lectures for a 
dozen years, and which I have made a prominent 
topic in all of my works and writings. But as the 
limits of this work will not permit me to discuss the 
subject at length, I can only refer the reader to my 
large book, the u Hydropathic Encyclopedia," and to 
some of my smaller works, particularly " Water-Cure 
for the Million," "Principles of Hygeio-Therapy," 
and " The Alcoholic Controversy," for a full exposition 
of the theory involved. 

The idea that diptheria " prostrates the person at- 
tacked," implies that the disease is a separate and dis- 
tinct entity from, and an existence outside of the living 
organism ; and this absurd theory is the basis of all 
the false medical science and bad medical practice in 
the world. The truth is, disease — all disease — is sim- 
ply the action of the living system in self-defense — a 
process of purification — a remedial effort. When this 
action occurs, when this struggle begins, the system 
may be in a condition of great obstruction or of 
extreme exhaustion, corresponding with and occasioned 



Pathology. 53 

by the personal habits, manner of life, occupation, 
exposures, etc., of the patient; and the form (not type) 
of the disease will be putrid or nervous, as one or the 
other of these conditions is most prominent, and its 
form or tendency (not type) will be mild or malignant, 
not according to some imaginary specific character of 
the morbid entity, or what authors so vaguely denomi- 
nate " epidemic constitution," but according to the 
greater or less putrescency or debility of the system. 
When medical men recognize these distinctions, they 
will have a much more rational pathology, and a 
vastly more successful practice. 

u The loss of muscular as well as nervous tone," and 
the numerous sequelw, in the shape of chronic diseases, 
which so generally follow the u attack" of diptheria, 
are, in my opinion, chiefly the effects of the drug- 
remedies — in other words, drug-diseases. 

So far as the treatment recommended in the preced- 
ing article is concerned, I will merely remark in this 
place that there are some things in it to commend and 
some to condemn, reserving the further discussion of 
the matter until I come to consider the therapeutic 
application of the principles I shall endeavor to estab- 
lish. 

Dr. Wood remarks : " In good constitutions the 
fever is usually sthenic ; but sometimes, especially 
when the disease prevails epidemically, it has a typhoid 
or malignant character, and this condition of the sys- 
tem reacts on the local affection" The expression which 
I have italicized is utter nonsense. The constitutional 
affection or condition does not act nor react on the 
local affection, nor does the local affection act nor 
react on the constitutional condition. The local affec- 
tion is an inflammation, and the constitutional affection 



54 DlPTHERIA. 

is a fever. Both together constitute the disease. The 
fever is never sthenic ; but in good constitutions, that 
is to say, in constitutions not very gross nor very much 
enfeebled, for the reasons already assigned, the fever 
will not be very low, but still it will be typhoid. And 
the inflammation, in diathesis, always corresponds with 
the fever; hence it is always low, passive, atonic, 
typhoid, asthenic. 

The doctrine is everywhere recognized in medical 
books, that a local inflammation and the accompanying 
fever may be of opposite diatheses, so that the reme- 
dies which are demanded by the local condition are 
injurious to the general system, and vice versa. This 
is one of the most pernicious of the many fallacies of 
a false medical system, as it inevitably involves the 
practitioner in the inexplicable muddle of " indications 
and eontra-indications," and necessitates the adminis- 
tration of remedies of the most conflicting "modus 
operandi" and insures the death of a large proportion 
of the patients. 

The inflammation and the fever — the local and the 
constitutional affection — in diptheria, as in all diseases, 
always correspond in character, in diathesis ; and the 
local affection never requires that treatment which 
aggravates the constitutional condition, nor does the 
general system ever demand any remedy or plan of 
treatment which is not also best for the local affection ; 
and when it is understood that the inflammation of the 
throat and the fever of the system are parts of one and 
the same disease, the idea of one "reacting" on the 
other is sufticiently absurd. 

Dr. Wood remarks further : " In the malignant 
cases the system is probably under some poisonous 
influence, superadded to that of the local affection." 



Pathology. 55 

Our author does not seem to have the remotest idea of 
any rationale of malignancy. Malignancy does not 
imply any " superadded" poison, but a great amount 
or quantity of poison, or a feeble organism. 

The distinction between the diptheritic exudation 
and apthous sore mouth, or thrush, is well explained 
by Dr. Wood: "In the thrush, the white coating 
appears first in separate points, w T hich afterward 
coalesce; is formed upon the surface of the epidermis, 
or at least not beneath it ; may be readily removed 
without affecting the integrity of the mucous mem- 
brane, or causing the least hemorrhage, and, when 
examined under the microscope, is found to contain 
abundantly a peculiar fungous plant. The diptheritic 
exudation forms in patches, beneath the epidermis; 
adheres strongly to the membrane, so that it can rarely 
be detached without causing the extravasation of some 
blood ; and under the microscope exhibits the ordinary 
constituents of false membrane; namely, interlacing 
fibrils, molecules or granules, and exudation or pus 
corpuscles. The exudation in scarlatina occurs gener- 
ally first in points, like the thrush, is much less cohe- 
sive than the diptheritic, less adherent to the mucous 
membrane, much less disposed to spread into the 
larynx, and also less disposed to make its appearance 
upon surfaces elsewhere that may be excoriated." 

Dr. McDonald, of Bristol, Eng. (Braithwaite's Ret- 
rospect, Jan., 1860), says, in relation to the identity 
of diptheria and malignant scarlet fever : " There has 
been considerable confusion with respect to scarlet 
fever and diptheria. Some have contended for the 
identity of the two, maintaining that those cases in 
which no rash appeared were to be considered as i sup- 
pressed scarlet fever.' To combat this view, it will be 



56 DlPTHERIA. 

sufficient, I think, to draw attention to the great differ- 
ence in the symptoms I have described from those of 
scarlatina, and to state the fact of its having been my 
painful experience to have attended families, some 
members of which have been swept off by scarlet 
fever with diptheria, while other members, who had 
previously suffered from scarlet fever in a severe form, 
were now attacked with true diptheria. That scarla- 
tina invites diptheria is very manifest, but that the 
diseases are perfectly distinct and different is equally 
certain." 

In another article, in the same number of JBraith- 
waite, J. 0. S. Jennings, Esq., of Malmesbury, Eng., 
says of the diptheria as it appeared under his observa- 
tion : " At the first outbreak of the disease no cases of 
scarlatina had appeared in the neighborhood, nor were 
there any until the second outbreak during the month 
of January in this year, when a few cases of diptheria 
occurred ; but scarlatina maligna ran through several 
families. In those cases, however, in which the rash 
was well developed and not suppressed, there was 
little or no throat affection ; and vice versa ; and when 
the tonsils were affected, there was not the peculiar 
leathery exudation of diptheria." 

Thomas Neckstall Smith, Esq., before quoted, in 
reference to the "type" (diathesis) of diptheria, re- 
marks {Braithwaite, part 46) : " Have we seen this 
disease before ? and what is its nature ? In answer to 
the first question, I can say confidently, that during a 
period of upward of thirty years' practice I had seen 
no case of diptheria until 1857. I had read Breton- 
neau's earlier papers many years since, and should 
have recognized the disease had it presented itself. 
Of its nature it is less easy to speak. It is evidently, I 



Pathology. 57 

think, a blood-disease, and not merely a local one. 
But what is the nature of that abnormal condition has 
yet to be explained, or, rather, I fear, has yet to be dis- 
covered. 

" In observing the progress of this epidemic I have 
been instinctively led to reflect on the altered type of 
disease in general. I have, myself, no doubt of that 
alteration in the type of disease, observed since the 
year 1832 in England. From that date there has been 
a departure from the old sthenic type, and this lias 
been more pronounced the last few years, until at 
length a genuine sthenic form of illness is almost, if 
not quite, unknown among us. We have, instead, low 
types of inflammation, low forms of cutaneous dis- 
eases, low types of fever, having more and more a 
tendency to the remittent form ; and a very marked 
increase in localities where it was before almost un- 
known, and where no known causes have arisen to 
occasion it, of intermittent fever. What was before 
a mere chill, a slight cold, thrown off with the first re- 
action, becomes now an attack of ague." 

The explanation of this change of diathesis, which, 
the author before us denominates " type," is not diffi- 
cult to understand, in the light of the premises I have 
advanced. The diathesis of disease always tends from, 
high to low — runs down, so to speak — as the constitu- 
tional vigor of the people declines. The change is not 
in the disease, per se, but in the habits of the people. 
Our fathers and grandfathers, our mothers and grand- 
mothers, when they had inflammatory and febrile dis- 
eases, manifested the high, active, entonic diathesis 
much more frequently than do their more effeminate 
sons and daughters. The lower the vital stamina, the 
lower will be the diathesis, because the more feeble 

3* 



58 DlPTHERIA. 

the vital struggle, in these remedial efforts which con- 
stitute the various forms of fevers and inflammations. 
Is it not strange that medical men have so long looked 
in the wrong direction for the solution of this problem ? 

Mr. Smith continues : " We have abundant evidence 
of this depression of vital power in the general symp- 
toms of diptheria. We have also a low type of local 
inflammation in unison with the general type ; but 
why it should just now seize the throat as its local seat 
instead of showing itself as boils, carbuucles, whit- 
lows, thecal abscess, necrosed bone, and in kindred 
forms, I do not know." 

JSTor will our author ever know if he forever pursues 
the phantom-entity which medical books denominate 
disease. The inflammation chooses to attack the throat ; 
it prefers that as its seat ; it seizes on that locality in 
preference to another ; it elects to manifest itself in the 
form of diptheritic exudation instead of carbuncular 
ulceration ! Such are the vagaries of learned medical 
men ! Such is the ridiculous nonsense which makes 
up the chief burden of medical books, and which is 
called science ! I am of opinion that the whole mys- 
tery lies in a false notion of the nature of disease, and 
that the reason why disease assumes one form instead 
of another is, because the living system, tinder all the 
circumstances, can best depurate itself of impurities by 
the actions which constitute the leading symptoms of 
the existing disease ; or, at least, can not, under the 
circumstances, make any other or different effort. To 
illustrate: if the system has sufficient power to de- 
termine the remedial effort chiefly to the surface and 
maintain it there, the fever, or the inflammation, or 
both when they co-exist — the diathesis — will be high, 
entonic, inflammatory, dynamic, or asthenic; but if 



Pathology. 59 

this is not the case, if the system is too gross or too 
feeble, the remedial effort will be directed mainly from 
the surface, and the diathesis will be low, atonic, ty- 
phoid, or asthenic. 

That diptheria and other forms of throat inflamma- 
tion run into each other, so to speak, by imperceptible 
gradations, is apparent to all who have had much expe- 
rience in treating these maladies. 

Says Dr. Edward Ballard, in an account of diptheria 
and epidemic sore throat, as they prevailed in the par- 
ish of Islington in 1858-'9: "The prevalence of sore 
throat not diptheritic in character, during the past 
year, has been matter of general remark. Many, if 
not most of these throats, exhibited some approach to 
the color of the mucous membrane when about to be- 
come the seat of diptheritic exudation. These sore 
throats appear to bear about the same relation to dip- 
theria as diarrhea bears to cholera in epidemic seasons. 
Just as in any cases of diarrhea, in an epidemic period, 
it is impossible to predicate that it will not pass into 
cholera, if neglected, so, in the ordinary sore throats 
which have lately presented themselves, no one would 
be bold enough to assert that any one might not before 
long exhibit the characteristic symptoms of true dip- 
theria." 

One more theory remains to be considered before 
dismissing this branch of our subject. Dr. T. Laycock, 
of Edinburgh, Scotland, has put forth the theory 
(Braithwaite, July, 1859), that the diptheritic exuda- 
tion depended on a parasitic fungus in the oidium 
albicans. This opinion is undoubtedly erroneous, as 
Dr. W. E. Rogers has explained : " The oidium albi- 
cans is not found in diptheritic exudation, unless in 
exceptional cases, and then only because the membrane 



60 DlPTIIERIA. 

has taken on an acid, putrefying change, this parasite 
requiring an acid, decomposing pabulum whereon to 
flourish, as is well proved by Berg and Gubler. In 
France, all know that this fungus distinguishes the 
pseudo from the true diptherite, the microscope being 
its test. Wherever this oidium is found it is muguet 
or thrush, plus whatever disease, acute or chronic, it 
may be, as I stated in my paper read before the Medi- 
cal Society. I have only found the oidium in one out 
of fourteen specimens, and this was fifty-six hours after 
the patient's death, though carefully examined twenty- 
four hours before. I may add that the leptothrix hue- 
calls mentioned by Dr. Wade is constantly to be found 
in the buccal mucus of healthy persons, if properly 
searched for. Dr. Harley, of University College, has 
stated to me that fatty acids are frequently mistaken 
for this fungus. True diptherite, in all the specimens 
I have examined, is a granular and cellular exudation, 
with some epithelial mucous corpuscles, and sometimes 
there may be found with it pus and blood-cells. I 
have but rarely distinguished fibrillse, or what looked 
like these. Under the exudation, the sub-mucous tis- 
sues and mucous membranes are usually thickened, 
and the mucous follicles are enlarged and filled with 
the same matter, which can be squeezed out, and from 
which the exudation seems to be produced ; but the 
cause of this change of mucus into membrane I do not 
desire at present to enter upon." 

As Dr. Laycock has published a reply to Dr. Rogers, 
through the London Lancet for January, 1859, my 
work would be incomplete without it, although I do 
not regard it as sustaining his position, while it may 
not be very interesting to the reader : 

*' If I understand Dr. Rogers' views aright, as re- 



Pathology. 61 

ported in the Lancet of the 22d inst., he not only thinks 
diptheria to be a blood-disease (which seems a probable 
theory), but that, as such, it can not be a parasitic dis- 
ease. Comparative pathology teaches, however, that 
this conclusion is, at least, doubtful. The muscardine 
(an epizootic disease of the silkworm) is due to a spe- 
cies of fungus like that which infests the potato, called, 
after its discoverer, the Botrytis Bassiana, and the 
sporules are described as being reproduced in the hlood 
of the insect when it becomes acid, while the filaments 
and mycelium appear on the respiratory surfaces — that 
is, at the outlets of the tracheal tubes. (Compare the 
engraving of the blood-appearances in M. Ch. Robin's 
valuable ' Histoire Naturelle des Yegetaux Parasites,' 
etc.) Again, the fungus of the common house-fly, 
named mycophyton Cohnii by Lebert, after Dr. Cohn, 
its first investigator, is a mold or oidium found in the 
blood, abdomen, and sometimes in the intestines of the 
insect at the beginning of autumn. (Lebert, Virchow's 
fi Archiv.,' etc., vol. xii., 1857.) Its first symptom ob- 
served is a milky appearance of the blood. It is found 
in the blood in all stages of development, from the 
simple minute spore, or cell, to the full-grown myce- 
lium. It is found in like manner in the fluids of the 
intestines, and appears externally as a mold. Flies 
thus affected may be often seen sticking, with out- 
stretched wings, to the window-panes, at the end of 
summer and beginning of autumn. These are by no 
means solitary instances of parasitic blood-disease. 
Indeed, hsemotophyta, as Lebert terms these micro- 
scopic blood-parasites, infest the blood of several classes 
of insects. References are given by Lebert loco citato. 
The same fact also holds good as to the vegetable para- 
sites. The common wheat bunt attacks the wheat, and 



62 DlPTHEKIA. 

makes it look and be sickly, when not the slightest 
trace of fungal thread can be found ; yet it is quite 
certain that something capable of reproducing the spe- 
cies is present at the time, either in the intercellular 
passages or protoplasm. This I state on the author- 
ity of Mr. Berkley. ('Introduction to Cryptogamic 
Botany,' 1857, p. 65.) That eminent observer is also 
of opinion that the Botrytis infestans is the fungus 
which is the cause of the potato disease. He says a 
crop may be seen to grow in a few hours from the cut 
surface of a diseased potato, even although the foliage 
exhibited no traces of the parasite ; and that the walls 
of the cavities of the carpels of the tomatoes are often 
covered with the fungus, though there is no communi- 
cation wdth the external air. These are facts which 
ought to make us hesitate, at least, in coming to the 
conclusion, in the absence of all inquiry, that a para- 
sitic disease can not be a blood-disease in man. The 
same kind of objection applies to the conclusions drawn 
from microscopic investigations by Dr. Rogers and 
Dr. Harley. A hundred examples of wheat infected 
with the tilletia caries (the bunt) might be examined in 
succession, or even a thousand, and no fungus detected ; 
but that would obviously be no proof that the diseased 
condition of the grain was not due to the parasite. It 
would simply signify that the diseased grain had not 
been examined at the proper stage of the development 
of the fungus. And I think the fact stated by Dr. 
Harley and Dr. Rogers, as to one of the twelve cases 
they examined, that the oidium albicans was developed 
twenty-four hours after no trace of it could be found, is 
significant of what may be, and I think is, the rule in 
the living body — namely, that certain conditions are 
necessary as to development, food, temperature, and 



Pathology. 63 

habitat, for the complete evolution of these organisms. 
There is no doubt that an acid condition accompa- 
nies the production and growth of the oidium in mu- 
guet, and of vegetable parasites on the skin in skin 
diseases ; but it is not so clear that the acid is the cause 
thereof. On the contrary, we know that the produc- 
tion of acid is itself due to fungi, as in the acetous fer- 
mentation. Dr. Lowe, of King's Lynn, differs from 
Gubler and others as to this acid theory, and I would 
particularly call Dr. Harley's attention to the account 
of Dr. Lowe's interesting experimental researches on 
these parasitic fungi, published last year, in the c Trans- 
actions of the Botanical Society of Edinburgh. 5 The title 
of Dr. Lowe's paper is significant of the caution with 
which microscopic researches should be made. It runs 
thus : i On the Identity of Achorion Schonleinii and 
other Parasites with Aspergillus Grlaucus.' Dr. Lowe 
believes he ' raised' aspergillus glaucus from the para- 
sitic fungus (the achorion of a case of porrigo lupinosa, 
treated in the Royal Infirmary here), and he got good 
yeast (torula cerevisise) from both the aspergillus and 
penecilium, which might, therefore, be got from the 
favus-fungus. Dr. Lowe infers, in fact, from his ex- 
periments, that all the fungi which produce skin dis- 
eases are referable to these two genera which produce 
yeast ; and conversely, that yeast may, under favorable 
circumstances, produce skin disease. The leptothrix, 
so common on the foul tongue, is probably to be classed 
with these favorable forms. These statements show, at 
least, how much is yet to be done in natural history 
before the true morbific action of these parasitic fungi 
can be determined. One thing, however, is certain, 
that the parasites of the potato, vine, apple, and silk- 
worm, all prevailing simultaneously, are almost identi- 



64 DiPTHERIA. 

cal with the oidium albicans ; and considering how 
readily a slight difference in the form of these minute 
organisms may be induced by differences in the food 
or habitat, it is probable that they are really identical 
in origin ; and this coincidence of spread can not but 
awaken a strong suspicion as to the relationship of the 
cause of diptheria to that of the epidemics of the silk- 
worm, vine, potato, etc. 

"That these parasites are sometimes powerful irri- 
tants of the living tissues is, I think, fully established, 
both from the history of muguet and other circum- 
stances. And although French writers speak of pseudo 
diptherite, the accuracy of the term may be questioned, 
for the exudation appears externally on ulcerated or 
exposed surfaces as w T ell as internally in both muguet 
and diptheria alike. An interesting case of vaginal 
blennorrhea, due, probably, to oidium albicans intro- 
duced from without, may be found in Virchow's 
' Archiv. fur Physiologie,' vol. ix., p. 466. The case is 
communicated by Dr. E. Martin, of Jena. The labia 
were swollen ; the vagina of bright red, studded with 
enlarged papillae, and covered with star-like patches of 
membrane like those of the mouth in muguet, which 
were found to contain the oidium albicans. A patient 
in the next bed (both were puerperal patients in hospi- 
tal) had subsequently active fever, abdominal tender- 
ness, and oidium albicans of the mouth, with muguet. 
Dr. Jos. Ebert, of Wurtzburg, found the oidium albi- 
cans in the crop, stomach, and intestinal canal of a 
hen. The upper portion of the latter was intensely 
red. 

" It is usual to speak of the characteristic pellicle as 
if it were peculiar to diptheria ; but this is by no means 
the case. It is not unfrequently seen in cases of typhus 



The False Membrane. 65 

and relaxing fever, sometimes in yellow fever, and, I 
believe, in all fevers. A series of carefully conducted 
experiments made with a thorough knowledge of cryp- 
togamic botany, on lower animals, so as to show the 
real pathological origin and effects of these parasitic 
fungi, would be very valuable. It would be absolutely 
necessary, however, that the animals experimented on 
be first brought as nearly as possible under, and into, 
the same conditions as persons are in who are attacked 
by the disease. I am inclined to think that it would 
probably be shown that these parasites may act either 
through the blood or locally only.' 5 

THE FALSE MEMBRANE. 

In all forms of disease — distinguishing action, which 
constitutes the essence of disease, from condition, 
which may be its cause, accompaniment, or effect — 
there is an effort on the part of the living organism to 
rid itself of abnormal conditions, effete matters, foreign 
substances, or what modern physicians have, with sin- 
gular absurdity, denominated " morbid poisons ;" in- 
deed, this process of depuration, as I have already 
explained, constitutes the " essential nature of disease.' 5 
When the process of depuration is directed mainly 
through the ordinary channels — the skin, liver, bowels, 
kidneys, and lungs — we have the simple fevers, vary- 
ing in form and phenomena, in type and diathesis, ac- 
cording to the quantity and quality of the impurities, 
etc., to be expelled, and the greater or less vigor of the 
various organs at the time ; these circumstances afford- 
ing the rationale of the distinctions of simple fevers 
into inflammatory, bilious, typhoid, continued, remit- 
tent, intermittent, ephemeral, etc. When the noxious 



66 DlPTHERIA. 

materials are determined almost wholly to the surface, 
and are of a nature to be eliminated only, except to a 
small extent, through the cutaneous emunctory, we 
have the various forms of eruptive fevers — small-pox, 
measles, scarlet fever, erysipelas, miliary fever, etc. 
In these eruptive fevers there is, in almost all cases, 
more or less expulsion of morbid matter upon the sur- 
faces of the mucous membranes, constituting an erup- 
tion, exudation, or ulceration of the part. In one form 
of scarlet fever — scarlatina maligna — the determina- 
tion of morbid matter is mainly to the throat, present- 
ing what has frequently been called "putrid sore 
throat." In some conditions of the system the noxious 
materials are thrown upon the mucous membrane of 
the trachea or windpipe, and so charged with the fibri- 
nous element of the blood — coagulable lymph — that, 
after being removed from its normal relations, it con- 
cretes into a false membranous coating, constituting 
true croup • or, if the fibrinous element is incapable 
of being thus partially or imperfectly organized, and 
is expectorated as a dense, glairy excretum, it consti- 
tutes the false or non-m&mbranous croup. When mor- 
bid matter thus affects the tonsils, or is specially 
determined to the mucous surfaces of the nose, or of 
the fauces, we have the common quinsy, or the catarrh, 
or the malignant quinsy — the " black tongue" of do- 
mestic animals. And when the fibrinous material is 
exuded over a greater or less portion of the mucous 
membrane of the mouth, whether or not involving the 
larynx, trachea, bronchia, and esophagus, it constitutes 
the disease which is generally recognized as diptheria. 
This exudation also occurs in some cases of diarrhea 
and dysmennorrhea, and in catarrh of the bladder ; or 
rather, the inflammatory process which excretes the 



The False Membrane. 67 

membranous matter is the cause of those particular 
forms of disease which have been termed tubular diar- 
rhea, painful menstruation, and catarrh of the blad- 
der. In these cases the membranous formation is 
usually broken up by the contraction of the parts, and 
expelled in fragments. In some cases, however, it has 
been cast off entire, and then not unfrequently mis- 
taken for a sloughing and expulsion of the mucous 
membrane itself. Even old and experienced professors 
of obstetrics, and authors of standard works on dis- 
eases of women, very often .mistake this morbid pro- 
duct for the " cast-off mucous membrane," when the 
uterus is the seat of the exudation. 

Dr. Winne has collated from various writers a very 
good description of the false membrane of ordinary 
diptheria. "When the mouth is examined upon the 
first day of the pseudo-membranous deposit, the parts 
destined to become the seat of the disease present the 
appearance of pieces of flesh bleached by contact with 
boiling water ; soon after there appears on the tonsils, 
the uvula, or the soft palate, small vesicular points of a 
lardaceous appearance, formed by the dissolving of the 
epithelium, which may readily be confounded with 
the minute yellow patches soon to appear. The mem- 
brane is almost invariably developed on one or the 
other of the tonsils, but not always, as the uvula is 
sometimes the original seat of the patches." 

Ordinarily, at the moment of formation, or soon 
after, the false membrane appears under the form of 
a white or a yellowish-white spot, rarely gray, quite 
circumscribed, a little projecting at its center, and sur- 
rounded by a circle of lively red. Sometimes the 
false membrane is semi-transparent and forms a slight 
pellicle, which envelops the tonsils, through which the 



68 DlPTHERIA. 

surface of this gland is partially visible ; but it soon 
loses this transparency and becomes of a yellowish- 
white color, extending itself to the subjacent parts 
with greater or less rapidity, according to a variety of 
circumstances, and especially the kind of treatment 
which has been adopted. After the false membrane 
has developed itself upon the tonsils, it usually extends 
to the soft palate, the uvula, and finally to the phar- 
ynx, with greater or less facility, regularly involving 
these different parts in the order here indicated. This 
is not invariably the case, for sometimes it is developed 
simultaneously in several distinct points, which finally 
converge the one into the other, and finish by forming 
a continuous surface. While it is thus enlarging its 
boundary, the false membrane acquires an additional 
thickness by the crossing of successive layers, so that 
it is not composed of one single film, but of many, 
which present a varied appearance, dependent upon 
the place occupied by them, " sometimes appearing like 
a deep ulcer with a yellow base ; at others, enveloping 
the uvula as a finger by a glove, and on the palate 
having the semblance of a deep hollow. 

"The period between the formation of this mem- 
brane and its dislodgment is very variable— usually 
from one to six days. In the early part of the disease, 
after being detached, a new membrane forms in its 
place, and this may be habitually reproduced several 
times. When the membrane is cast off spontaneously 
about the sixth or seventh day, its place is seldom sup- 
plied by a new deposit ; and about the tenth day the 
patient is convalescent. When the case terminates 
fatally, the original inflammation extends to the air- 
passages, and not unfrequently to the nasal cavities, 
which likewise become the seat of a pseudo-membrane, 



The False Membrane. 69 

greatly augmenting the sufferings of the patient and 
the gravity of the disease, whose termination is herald- 
ed by the fetid, sanious discharge from the nostrils, 
and symptoms of angina, which speedily supervene. 

" When the termination is hastened by the super- 
vention of gangrene, the pseudo-membrane loses its 
consistency, is easily detached, changes to a grayish 
color frequently mixed with bloody spots, and is coated 
with a sanious fluid which flows from the mouth and 
nostrils, and emits a very fetid odor. The flow of 
blood in these cases is sometimes considerable, and not 
unfrequently covers the lips and nasal cavities, in 
which latter the flow is often arrested by the formation 
of clots. 

u Whatever may be the time at which the false 
membrane becomes detached, it generally exhibits the 
subjacent tissues diminished in size, and of a redness 
more or less intense in color. This diminution in size 
is especially noticeable in the tonsils and uvula. The 
false membrane does not always occupy the same seat." 

Dr. Pichenot, in a report to the Paris Academy of 
Medicine, describes the local symptoms of a very fatal 
diptheria which prevailed epidemically in the Com- 
mune of Oreusery, in 1855 : " The tonsils press upon 
the folds of the soft palate, and their surface is injected 
with a grayish deposit. But it is upon the mucous 
membrane of the posterior portion of the throat that 
the diptheritic plagues usually present themselves, and 
their grave condition here almost invariably presages 
grave and rapid disease, and not unfrequently a fatal 
termination. The pain in the head and neck now be- 
comes augmented, the respiration more difficult, the 
face edematous, and the maxillary glands tumefied and 
sensitive to pressure. 



70 DlPTHERIA. 

" Its march is very rapid. In the space of from 
three to five hours the papular eminences of the throat 
become covered with a flocculent, transparent vail, of 
white appearance. Generally, not more than one half 
of the guttural cavity is at first invaded. The remain- 
der of the mucous surface of the throat, the uvula, 
and the nasal cavities not being affected by the 
membrane, which soon loses its transparency, aug- 
ments notably in thickness, and degenerates into the 
true diptheritic membrane, of a gray or yellowish 
color. 

" The false membrane is not always continuous, and 
I have seen several times the tonsils, and the pharynx, 
in whole or in part, recovered from the membranous 
deposit while it was progressing upon the soft palate. 
The membranous fold is easily separated by traction, 
the use of caustics, and often by Nature, when it ap- 
pears circumscribed by a red circle. In all these cases 
it returns again very promptly, but is less thick, and 
is often reproduced upon a surface, which exhales a 
fetid and sanious liquid. In some very rare cases the 
membrane never falls, but is slowly reabsorbed. The 
voice becomes nasal; the mouth, which rests open, and 
the nostrils, exude continually an ichorish fluid, which 
becomes more fetid as the disease progresses, and 
thickened with the exfoliated shreds of the false mem- 
brane. The head, neck, and chest often present a uni- 
form plane, in which the swelling is considerable. Res- 
piration and deglutition are rendered almost impossi- 
ble, by the increased size of the tonsils and the in- 
vasion of the false membrane ; the prostration is ex- 
treme ; the patient is not able to raise his head ; the 
pulse becomes imperceptible, the extremities cold, the 
intelligence almost always intact, the lips cyanosed, 



The False Membkane. 71 

the eyes vitreous, and death comes to terminate the 
frightful spectacle. 

"Such are generally the symptoms when the case 
terminates fatally. During the first four months of 
the epidemic, death occurred from the second to the 
fourth day of the disease, and life was rarely prolonged 
beyond the sixth. Upon the decline of the epidemic, 
the progress of the disease was more tardy, and fre- 
quently extended to the tenth day." 

M. Bretonneau thus describes the specific character 
of the diptheritic exudation : 

" At the beginning of the disease there is perceived 
a circumscribed redness, which is covered with semi- 
transparent coagulated mucus. This first layer, thin, 
supple, and porous, may be still elevated by portions 
of the unaltered mucous membrane in such a manner as 
to form vesicles. Often in a few hours the red patches 
visibly extend step by step, through continuity or con- 
tact, in the manner of a liquid which is poured out on 
a plane surface, or which runs by striae into one chan- 
nel. The concretion becomes opaque, white, and thick ; 
it assumes a membranous consistence. At this period 
it is easily detached, and adheres to the mucous mem- 
brane only by very delicate prolongations of a concrete 
matter, which penetrates into the municiparous folli- 
cles. The surface which it covers is usually of a slightly 
red tint, dotted with a deeper red ; this tint is more 
vivid at the periphery of the patches. If the false 
membrane be detached, and leave exposed the mucous 
surface, the redness which appeared subdued under 
the concretion reappears, blood transudes through the 
deep red points, the concretion reappears, and becomes 
more and more adherent upon the points first invaded. 
It often acquires a thickness of several lines, and passes 



72 DlPTHERIA. 

from a yellowish-white to a grayish and to a black 
color. At the same time the blood transudes with 
more facility, and constitutes those stillicidia which 
have been generally remarked by authors. 

"Now, the alteration of the organic surfaces is more 
apparent than at the beginning ; often portions of con- 
crete matter are effused into the substances itself of the 
mucous membrane ; there is observed also a slight 
erosion, and sometimes echymosis in points, which, by 
their situation, are exposed to friction, or from which 
the avulsion of the false membranes has been attempt- 
ed. It is especially about this time that the concre- 
tions which have become putrid give out infectious 
matter. If the concretions are circumscribed, the ede- 
matous swelling of the cellular tissue immediately 
around makes the former appear depressed, and, judg- 
ing from this appearance only, we might be tempted 
to believe that we had under observation a foul ulcer 
with considerable loss of substance. 

" If, on the contrary, they are extended over consid- 
erable surface, they become partially detached, and 
hang in shreds more or less putrefied, and simulate the 
last stage of spachelus ; but when we open the body of 
those who, several days sick, have succumbed to tra- 
cheal diptheritis, we shall find in the air-passages all 
the shades of this inflammation from its first degree, as 
shown in the portions just invaded, up to that which 
has, by its deceptive appearance, led us for a moment 
to dread the supervention of gangrene." 

M. Empis regards the commencement of the false 
membrane as a process of coagulation, which takes 
place by a precipitation of fibrin, independently of any 
agency of the living tissue. This is to be seen most 
distinctly in the air-passages, particularly in the larynx 



The False Membrane. 73 

and trachea, in which the tubular cast is seldom adher- 
ent, and is commonly much smaller than the cavity it 
occupies; its external surface, therefore, being sepa- 
rated by a considerable interval from the mucous 
membrane. That coagulation is not occasioned by the 
influence or action of the mucous membrane is re- 
garded by M. Empis as proved by his experience in 
cases where tracheotomy has been performed : 

"At the end of a few hours after the operation, 
whatever care might be taken to clear the canula, the 
instrument was seen to be lined with a layer of whitish 
concretions, the thickness of which continually in- 
creased. These concretions were evidently only the 
result of the coagulation of the liquid by which the 
sides of the canula were constantly covered. 

" The pellicle thus formed," says Dr. Slade, of Bos- 
ton (" Diptheria ; its Nature and Treatment"), " which 
may be considered as the first degree of false mem- 
brane, is thicker at the center than at the circumfer- 
ence, and generally may be lifted up, although in very 
small pieces, owing to its friability. Beneath this su- 
perficial pellicle, according to M. Empis, there is still 
an exudation of sero-mucous matter, which gradu- 
ally coalesces with the pellicle already formed, thus 
producing a false membrane several lines in thick- 
ness, and adhering to the subjacent surface very 
closely. 

" In many cases the membrane thus formed appears 
to remain for some time stationary, and then, sooner or 
later, it takes on an increase in thickness as well as in 
extent of surface. The secretion of sanious fluid which 
imbues and softens the concretions is also increased, 
becomes very dark-colored, and exhales a fetid odor, 
similar to that of gangrene. This especially applies to 

4 



74: DlPTHERIA. 

the deeper portions of the fauces, to the vulva, and to 
the anterior parts of the vagina." 

M. Empis remarks, with regard to the cicatrization 
of the membrane : 

" We never see the membrane disappear all at once, 
leaving in its place a cicatrized surface, as is the case 
with an ordinary eschar, but it is by a gradual process 
that the pellicle diminishes in thickness, in proportion 
as the edges of the abraded surface cicatrize. If, how- 
ever, we modify the secreting surface by an energetic 
local treatment, we can cause the complete disappear- 
ance of the membrane, leaving nothing beneath but a 
granulating surface of a healthy character." 

Any portion of the external surface of the body 
where the epidermis is absent, and also the surfaces of 
ulcers and wounds, may become affected with dipthe- 
ritic exudation as well as the mucous membrane. In 
some cutaneous affections which have prevailed epi- 
demically, and especially in France, the " cutaneous 
diptheria" has been a prominent feature. Blistered 
surfaces, leech, bites, excoriations of any part, when 
the disease prevails epidemically, are liable to become 
the seat of diptheritic inflammation ; and the external 
manifestation of the diptheritic poison is said to be at- 
tended with results quite as disastrous as are its de- 
positions on the mucous membrane. 

" When a wound is attacked by diptheritic inflam- 
mation," says Dr. Slade, "it becomes painful, fetid, 
and discolored ; serosity pours from it in abundance, 
and a gray, soft coating soon covers it with a layer of 
increasing thickness ; the edges swell and become 
? violet. The wound remains often obstinately station- 
ary for months ; sometimes it spreads, then around it 
an erysipelatous blush is seen ; pustules form, become 



The False Membkaete. 75 

confluent, burst, and leave apparent a diptheritic 
patch, which spreads even from the head to the loins. 

" A curious fact which has been observed as regards 
the seat of diptheritic exudation is, that although it is 
found equally in the mouth, on the soft palate, the ton- 
sils, the pharynx, the nasal fossae, the larynx, trachea, 
and even in the bronchial tubes, on the conjunctiva, 
the vulva and anus, and upon the skin, it is not found 
upon those portions which are removed from the con- 
tact of the air ; these seem refractory to the extension 
of the disease. M. Empis remarks that he never saw 
true diptheria extend into the esophagus ; while, on 
the contrary, the exudation of certain apthous affec- 
tions shows a great tendency to spread into the esoph- 
agus, but never into the respiratory organs. The 
atmosphere would thus certainly seem to exert an in- 
fluence in promoting diptheritic inflammation." 

I must reason a little differently from the authors 
just quoted. I do not think the facts prove that " at- 
mospheric air promotes diptheritic inflammation," but 
that after the diptheritic excretion has taken place, the 
influence of the atmosphere will favor the concretion 
of the fibrinous material exuded into the dense coating 
which constitutes the false membrane. And this ex- 
planation is corroborated, if not absolutely demon- 
strated, by the fact that the membrane is not unfre- 
quently formed in the bowels, bladder, and uterus, as 
we have already seen. 

M. Empis, who has examined the false membrane 
microscopically, declares that it is impossible to draw 
any distinction, founded on microscopic investigation, 
between the exudation of diptheria and that of a blis- 
tered surface, or that which occurs in the throat affec- 
tion of malignant scarlet fever. 



76 DlPTHERIA. 



HISTORY OF DlPTHERIA. 

The first distinct description of a form of malignant 
sore throat is found in the writings of Aretseus, who 
lived about the time of Galen, under the name of 
Egyptian or Syrian ulcer. Macrobius mentions a simi- 
lar disease which prevailed in Rome, A.D. 380 ; and 
" there is reason to suppose," says Dr. Greenhow, 
" that we can trace back the history of this affection to 
a period almost cotemporary with Homer." In 1337 a 
fatal epidemic of sore throat occurred in Holland. In 
1576 it prevailed epidemically in Paris. In 1618-19 
it destroyed five thousand victims in Naples ; and 
about this period it prevailed as an epidemic in Spain 
for forty years. In 1636 it prevailed at Kingston, Ja- 
maica ; in 1736 it appeared in Boston, and in 1743 it 
reappeared in Paris, where it continued until 1748. 
In 1749 it appeared at Cremona and in England. In 
1770 it was first noticed in New York and described 
by Dr. Samuel Bard. 

Dr. Winne, in the paper heretofore mentioned, pre- 
sents a rapid sketch of the most important historical 
data, from which I extract : 

" It was not, however, until its appearance at Tours 
in 1818, that it assumed the name of Diptherite, by 
which it is generally recognized in England and the 
United States, at the hands of M. Bretonneau, whose 
investigations have largely contributed to the present 
fund of knowledge on this subject, and to whom the 
first connected and practical researches are due. Dip- 
therite made its first appearance at Tours in 1818, in 
the barracks of the soldiers, in the rear of the legion of 
La Yendee, and from thence spread to the surrounding 



History. 77 

quarters. The attack among the soldiers was usually 
a gingival diptheria, but as it spread into the city the 
larynx became the seat of the disease, and the gums 
were not largely affected. From Tours the disease 
slowly spread to La Ferriere, which it reached in 1824, 
where, out of two hundred and fifty inhabitants, 
twenty-one were attacked and eight died. In 1825 
the communes north of Orleans were attacked; and in 
1828 those south of Orleans suffered from this disease. 
" In 1821 M. Bretonneau presented a memoir to the 
Academy of Medicine, at Paris, on diptheria, as it had 
prevailed at Tours, which was followed by several 
others in subsequent years. The whole of his laborious 
and exact researches were finally given to the world in 
his treatise entitled, ' Des inflammations speciales du 
tissu muqueux et en particulier de la diptherite, ou in- 
flammation jpelliculaireP From the period of its out- 
break at Tours, diptheria appears to have seldom or 
never been absent from one or the other of the depart- 
ments of France, pursuing a very erratic course, both 
as to its mode of visitation and the intensity of its 
attacks, so that the annual reports of the French Acad- 
emy of Medicine on prevailing epidemics seldom fail 
to note its existence in some portions of the empire. 
The visitations, however, which have produced the 
greatest alarm, not only on account of their severity, 
but also because of the respectability of the victims, 
were those of Paris and Boulogne in 1855. The dis- 
ease at Paris attacked both rich and poor, and while it 
carried off a large number of children, proved fatal to 
many adults, more especially those who were often in 
attendance upon the sick. Among these was the emi- 
nent medical writer, Valleix. That, however, at Bou- 
logne was not only the gravest, but of the longest du- 



78 DlPTHERIA. 

ration, continuing from January, 1855, to March, 1857. 
During this period it caused 366 deaths, of which 341 
were of children under ten years of age. In this epi- 
demic, as in that of Paris, no condition was spared ; 
and, indeed, the attack seemed to fall with the greatest 
severity upon the children of the wealthy English resi- 
dents, who, from their more favorable, hygienic position, 
might be supposed to enjoy a comparative immunity 
from epidemic disease. 

" Nor does its fatality appear to have been diminished 
in subsequent years, for in the report for 1858, read by 
Trousseau, 22d November, 1859, it is stated that dip- 
theria prevailed in 31 departments, and attacked 1,568 
adults and 7,474 children; of these, 165 adults and 
3,384 children died. 

"In England, the disease first presented itself in the 
south-eastern counties nearly opposite Boulogne, in the 
early part of 1857 ; and traveling from station to sta- 
tion, visited especially the ill-drained and marshy dis- 
tricts, and the neglected and unhealthy localities in 
towns. Some of the first cases occurred in the practice 
of Mr. Rigden, of Canterbury, at the beginning of the 
year. He describes ' seven cases of diptheritic inflam- 
mation of the fauces and tonsils, attended with consid- 
erable fever, depression and swelling of the tonsils, the 
fauces and part of the mouth being covered with a 
pasty lymph.' From this point it gradually diffused 
itself through the eastern counties, fastening especially 
upon the marshy districts, in which the attacks were 
numerous, although the mortality was not in propor- 
tion to the number of cases. During the winter months 
of 1857 it had largely diffused itself through the county 
of Essex, causing eight out of twenty deaths, and en- 
hancing the rate of mortality in Suffolk and Norfolk 



History. 79 

in the proportion of three to one. The disease appeared 
to lull during the summer, but in the autumn of 1858 
it largely extended its boundaries, and became quite 
prevalent in the north midland counties. The county 
of Lincolnshire appeared to suffer more severely than 
any other in England, no less than eighty-two deaths 
being; attributed to this cause. In the northwestern 
counties it prevailed in conjunction with whooping- 
cough, and in Nantwich caused thirteen out of fifty- 
nine deaths. It was observed at Wigan, Liverpool, 
and Hulme, as well as at Rosendale, in which latter 
place sixteen out of sixty-eight deaths were attributed 
to its influence. 

"Diptheria prevailed at Lima, South America, in 
1855, and again in 1858, and is very well described in 
the concise account given by Dr. Odriazala, a Spanish 
physician, resident at Lima. In 1855 it appeared in 
California, and prevailed extensively not only in San 
Francisco and Sacramento, but likewise in the various 
mining districts throughout the State. In Placer 
County it was quite prevalent, but among the districts 
which suffered most was that of Sonora. The number 
of cases was very numerous, and the deaths in the ag- 
gregate large, but there is no means of determining 
the relative proportion which they bore to the number 
affected. Dr. Blake states that at Cache Creek, about 
twenty miles from Sacramento, the children during 
1855 and 1857 were almost decimated by this disease. 
At Cache Creek it was principally during the spring 
and summer months that the disease showed itself; 
and Dr. Bynum, who had attended nearly two hundred 
cases, states that the affection always appeared more 
virulent after the prevalence of a north wind, which is 
a dry and cold one. 



80 DlPTHERIA. * 

" In regard to the conditions under which it appear- 
ed, Dr. Blake says it is usually stated that ' it generally 
prevails in low situations, and to a certain extent this 
is true ; although the most fatal epidemic of the dis- 
ease that came under my observation was at a mining 
village called Dutch Flat, situated in a hollow sur- 
rounded by hills, about 4,000 feet above the sea. There 
were thirteen children in the village, all of whom were 
attacked, and four died. At Grass Valley, which is 
similarly situated at an altitude of 2,300 feet, the num- 
ber of cases was great, and the mortality considerable. 
It was chiefly, however, in the Sacramento valleys and 
in the valleys of the coast range that the disease was 
most prevalent.' The disease again renewed its at- 
tack in 1858, and is accurately described by Dr. Four- 
geaud, in a ' Concise and Critical Essay on the late 
Pseudo-Membranous Sore Throat of California.' 

" The most alarming as well as the most fatal out- 
break of the disease in the United States occurred in Al- 
bany, in 1858. The first case occurred in the south part 
of the city, on the 2d of April of that year ; the second 
on the 20th of April, in the same section of the town. 
From this time it continued to increase in numbers and 
severity. During the twelve months in which it reign- 
ed as an epidemic it attacked about two thousand per- 
sons, and caused one hundred and ninety-seven deaths, 
of which but three were adults. 

"The first death from diptheria reported from the 
office of the City Inspector, in New York, occurred on 
the 20th of February, 1859, in the practice of Dr. 
Maxwell ; the residence of the child, who was three 
and a half years old, was in 38th Street, near 5th 
Avenue. The second death occurred at Manhattan- 
ville, on the 25th of February ; on the same day, a 



History. 81 

third fatal case was reported from Stanton Street. On 
the 5th of March, the fourth case was reported from 
Vesey Street; on the 10th of March, the fifth from the 
lower end of 28th Street ; on the 23d of March, the 
sixth from Grand Street, near the East Kiver ; and on 
the 28th of March, the seventh from Varick Street. 
During the month of April three deaths were re- 
ported ; in May, three ; in June, two ; in July, two ; 
in August, four ; in September, five ; in October, nine ; 
in November, seven ; and in December, ten. The 
whole number of deaths for 1859 was 53, of which 30 
were males and 23 females. During the year 1860, 
the number of fatal cases considerably increased, and 
the prevalence of the disease as reported at the various 
Dispensaries was largely augmented. From the 1st to 
28th January, 1860, 14 deaths were reported by the 
City Inspector. For the week ending February 4th, 
10 deaths ; for that ending the 11th, 12 deaths ; week 
ending 18th, 10 deaths; for week ending 25th, 14 
deaths ; for week ending 3d March, 19 deaths ; for 
week ending 10th, 9 deaths ; for week ending 17th, 
13 deaths. The whole number of deaths from dipthe- 
ria in 1860 was 422. 

" Previous to the report of the cases above alluded 
to, some deaths from diptheria were returned to the 
City Inspector, but were reported under the head of 
croup. The number included in this category it is not 
possible to determine, but it may be fairly inferred 
that they were not numerous. During the latter part 
of 1858 and the early part of 1859, a remarkable ten- 
dency to affections of the mucous membranes, es- 
pecially of the throat, was observed, and this became 
so general as to constitute an important element in the 

medical man's daily practice. Nor was this confined 

4* 



82 DiPTHERIA. 

to any particular part of the city, or class of persons, 
but seemed to pervade alike the habitations of the 
opulent, and the confined, ill- ventilated apartments of 
the poor. As yet, however, no diptheria had been ob- 
served, and it was not until about the month of March 
that medical practitioners here and there, especially 
among the poor, observed a thin, pellicular covering 
over the tonsils, interspersed here and there with white 
star-like specks, which gradually expanded in size, and 
in severe cases came to cover the whole of the tonsils, 
and extend over the other soft parts of the throat into 
the larynx on the one side and the nares on the other. 
This film-like substance could be easily removed with 
the sponge in its earlier stages, but became dense and 
closely adherent as the disease progressed. 

"Reports of a similar disease have been received 
from every part of the United States; and in many 
of the larger places, as Boston, Providence, Philadel- 
phia, Baltimore, Richmond, New Orleans, Cincinnati, 
Louisville, and St. Louis, as well as in the rural dis- 
tricts, well-marked cases of diptheria have been ob- 
served, and in each the bills of mortality have been 
increased to a greater or less extent through its agency. 
Although the means of tracing the progress of this 
disease through the United States do not exist, yet a 
sufficient number of facts is known to establish that 
it has not as in England, and to some extent in France, 
pursued a progressive line of march, but has presented 
itself here and there in the most erratic manner, and 
without the general and wide-spread disposition to af- 
fections of the mucous membranes which everywhere 
prevailed, and for the most part still continues." 

In his account of the " sweating sickness" in Eng- 
land, in 1517, Hecker says (" Epidemics of the Middle 



History. 83 

Ages") : " In January of that year there appeared in 
Holland another disease which, from its dangerous and 
inexplicable symptoms, spread fear and horror around. 
It was a malignant and infectious inflammation of the 
throat, so rapid in its course, that, unless assistance 
was procured within eight hours, the patient was past 
all hope of recovery before the close of the day. Sud- 
den pains in the throat and violent oppression of the 
chest, especially in the region of the heart, threatened 
suffocation, and at length actually produced it. Dur- 
ing the paroxysms the muscles of the throat and chest 
were seized with violent spasms, and there were but 
short intervals of alleviation before a rej)etition of such 
seizures terminated in death. Unattended by any pre- 
monitory symptoms, the disease began with a severe 
catarrhal affection of the chest, which speedily ad- 
vanced to inflammation of the air-passages. In Basle, 
within eight months, it destroyed 2,000 people." 

In the year 1736, Dr. Douglass, of Boston, published 
an account of the first appearance of a u sore throat 
distemper" in this country. The epidemic which he 
describes was very malignant, and was attended with 
" erysipelatous appearances and highly putrid symp- 
toms." 

Under date of October 1, 1753, Mr. Cadwallader 
Golden addressed a letter to Dr. Fothergill concerning 
the " throat distemper," which was published in the 
first volume of " Medical Observations and Inquiries," 
London. Mr. Colden says : 

" The first appearance of the throat distemper was 
at Kingston, an inland town in New England, about 
1735. It spread from there, and spread gradually 
westward, so that it did not reach Hudson's river till 
nearly two years afterward. It continued on the east 



84 DlPTHEKIA. 

side of Hudson's river before it passed to the west- 
ward, and appeared first in those places to which the 
people of New England resorted for trade, and in the 
places through which they traveled. It continued to 
move westwardly, till I believe it has at last spread 
over all the British colonies on the continent. Chil- 
dren and young people were only subject to it, with a 
few exceptions of some above twenty or thirty, and a 
very few old people who died of it. The poorer sort 
of people were more liable to have the disease than 
those who lived well with all the conveniences of life, 
and it has been more fatal in the country than in great 
towns. 

" In some families it passed like a plague through 
all their children ; in others, only one or two were 
seized with it. Ever since it came into the part of the 
country where I live (now about fourteen years), it 
frequently breaks out in different families and places 
without any previous observable cause, but does not 
spread as it did at first. It seems as if some seeds, or 
leaven, or secret cause remains wherever it goes. 
When the distemper becomes obvious, it has the com- 
mon symptoms attending a fever, except that a nausea 
or vomiting is seldom observed to accompany it. The 
disease is not often attended with that loss of strength 
that is usual in other fevers ; so that many have not 
been confined to their beds, but have walked about 
the room till within an hour or two of their death; 
and it has often appeared no way dangerous to the 
attendants, till the sick were on their last agony. Some 
died on the fourth or fifth clay, others on the fourteenth 
or fifteenth day, or even later. When this disease 
first appeared, it was treated with the usual evacuations 
in a common engina, and few escaped. In many fam- 



History. 85 

llies, who had a great many children, all died ; no 
plague was more destructive." 

One source of the fatality of the epidemic described 
by Mr. Oolden is indicated in that significant line, 
"it was treated with evacuants, and few escaped." 
The whole history of all malignant epidemics shows 
that the depleting practice of the physicians has caused 
more deaths than would have occurred had the disease 
been left to itself, and the powers of life to their own 
unaided resources. 

A throat-disease, in all essential particulars, pre- 
vailed in Sullivan County, N. Y., in November and 
December, 1861 (principally in the town of Lock Shel- 
drake and its immediate vicinity), and although there 
was no dearth of doctors (from three to six consulting 
together in some of the cases), every case proved fatal. 
Several families lost all of their children. In the family 
of a Mr. Kyle, of eleven children, nine died. Almost 
all the deaths in this neighborhood occurred in about 
forty-eight hours after the first alarming symptoms. A 
large proportion of these patients were adults. 

In the epidemic sore throat which prevailed in New 
York in 1771, as described by Dr. Bard, the disease 
was generally confined to children under ten years of 
age. The symptoms were usually so mild for five or 
six days as to create little alarm ; after which occurred 
very great and sudden prostration of strength, a pecu- 
liar hollow, dry cough, and a remarkable change in the 
tone of the voice, indicative of ulceration in the laryn- 
geal passage, or a concretion of the exuded lymph. 

In the cases described by Dr. Bard, the swelling of 
the parotid, sublingual, and submaxillary glands, men- 
tioned by other authors as invariably present, was 
noticed in but few instances. 



86 DiPTHERIA. 

In the spring of I860, the disease appeared endemi- 
cally near New Haven, Conn., and is thus described 
by Dr. L. N. Beardsley, of Milford — who attended the 
first fifteen cases — in a communication to the Boston 
Medical and Surgical Journal : 

" This disease [diptheria] appeared in an endemic 
form, and with great mortality, in this vicinity during 
the months of March and April last. It first made its 
appearance in Orange, an adjoining town (which is in 
an elevated situation, and is a remarkably healthy 
place, with a sparse population), and for a while was 
confined entirely to the scholars attending a select 
school in the village. Fourteen out of fifteen of the 
cases, of those who were first attacked, proved fatal, in 
periods varying from six to twenty-four days. 

" Most persons residing in the district where the 
disease first appeared, sooner or later had some mani- 
festations of the disease. The period of incubation 
varied from five to twenty days. The lymphatic 
glands w r ere in many cases greatly enlarged. The first 
symptom — and it is one which we have never seen 
referred to by any writer on the subject — was pain in 
the ear. It was not only pathognomonic but promi- 
nent, and almost invariably present in every case that 
came under our observation, in a day or two before 
the patient made the least complaint in any other 
respect, and before the smallest point or concretion of 
lymphatic exudation could be discovered on the tonsils 
or elsewhere." 

The language of Dr. Beardsley is a little muddled. 
To be " pathognomonic," a symptom should be inva- 
riably present, and not " almost invariably," as our 
author expresses it. 

During the years 1860 and 1861 diptheria has pre- 



Infectiousness. 87 

vailed sporadically or endemically in nearly all sec- 
tions of the United States, and at this time, so fa.r as I 
can learn from extensive correspondence with all parts 
of the country, it seems to be on the increase. 

INFECTIOUSNESS. 

Is diptheria contagious ? This question has been 
much discussed by medical writers, and, as has been 
the case with scarlet fever, yellow fever, plague, and 
some other diseases, the testimony adduced pro and con 
seems to be pretty equally balanced. I suspect that 
the disputants on both sides of the question in issue are 
partly right and partly wrong. I am of opinion that 
under certain circumstances all febrile diseases may 
be contagious. In all fevers there are morbid excre- 
tions which, if due attention is not paid to ventilation 
and cleanliness, may become so accumulated and con- 
centrated, as it were, as to infect other persons, and 
thus become the cause of a similar disease in them. 
Much depends, of course, on the greater or less sus- 
ceptibility of the individual to be affected, and this 
susceptibility, or non-susceptibility, is nothing more 
nor less than the grossness or purity of the party 
exposed. 

Several authors, among whom is M. Bretonneau, 
have maintained that the exuded matter of diptheria 
possesses a special virulence, and that the disease may 
be propagated by the application of the secretion 
[excretion ?] from an affected surface to sound parts, 
like small-pox ; and he contended that, like syphilis, 
the disease can only be communicated by contact, thus 
rendering it technically infectious, as is syphilis, in- 
stead of both infectious and contagious, as is small-pox. 



88 DlPTHERIA. 

M. Bretonneau says : " Innumerable facts have 
proved that those who attend patients can not contract 
diptheria unless the diptheritic secretion in the liquid 
or pulverulent state is placed in contact with the 
mucous membrane, or with the skin on a point denuded 
of epidermis, and this application must be immediate. 

" The ' Egyptian disease' is not communicated by 
volatile invisible emanations, susceptible of being dis- 
solved in the air, and of acting at a great distance from 
their point of origin. It no more possesses this quality 
than the syphilitic disease. If the liquid which issues 
from an Egyptian chancre, as visibly as that which 
proceeds from a venereal chancre, has seemed under 
certain circumstances to act like some volatile forms 
of virus, the mistake has arisen from its not having 
been studied with sufficient attention. The appearance 
has been taken for the reality." 

In support of the doctrine of the infectious nature 
of diptheria, M. Bretonneau has adduced the following 
among other cases : In the hospital at Tours, a child 
affected with diptheria, in a fit of coughing, ejected a 
portion of the diptheritic matter which lodged upon 
the aperture of the nostril of M. Herpin, the surgeon, 
who was at the time sponging the larynx of the patient. 
This M. Herpin neglected immediately to remove, and 
the result was a severe diptheritic inflammation which 
spread over the whole nostril and pharynx, attended 
with extremely severe constitutional symptoms, with 
great prostration, and followed by a slow and lingering 
convalescence of six months' duration. This child, it 
is also stated, had transmitted the affection to its 
nurse. 

Dr. Gendron, of Chateau de Loire, having received 
on his lips portions of diptheritic exudation, expelled 



Infectiousness. 89 

by a patient in the act of coughing, was soon affected 
with a violent laryngeal inflammation. 

In 1826 a boy, affected with frost-bites of his foot, 
had a painful diptheritic inflammation of the great toe, 
soon after using a bath that had been employed for a 
diptheritic patient. 

M. Bretonneau concludes from his experiments and 
observations, that the disease can not be occasioned by 
atmospheric communication, and is not therefore con- 
tagious ; but that its cause is transmissible by inocula- 
tion, and is therefore strictly infectious. And his 
observations are corroborated by other authors. 

But, on the other hand, Prof. Trosseau, who inocu- 
lated himself and two of his pupils with diptheritic 
matter, failed to produce any results whatever ; and 
Dr. Harley, of London, was equally unsuccessful in 
experiments on domestic animals. 

The experience of M. Isambert, of Paris, as. related 
in a communication on the epidemic of malignant sore 
throat which occurred in Paris in 1855, goes to prove 
that diptheria is contagious as well as infectious. He 
says : u Diptheritic affections sometimes appear spo- 
radically ; they also often seem to be endemic, as well 
as epidemic and contagions. As predisposing causes, 
we may consider that the lymphatic temperament, a 
feeble constitution, privation, etc., all exert a decided 
influence. Youth is much more exposed to the disease 
than any subsequent age. Locality and overcrowding 
have a positive effect ; so also do cold and changeable 
seasons. 

•'Epidemic influences are much the most powerful. 
As to the contagious nature of the disease there can be 
no doubt, since many physicians have contracted it. 
The opinion of M. Bretonneau, that diptheria is not 



90 DlPTHEEIA. 

transmitted by the atmosphere, but is always the result 
of inoculation, is altogether too exclusive. "With M. 
Trosseau, we can not reject infection at a distance 
as one of the means of propagation possessed by 
diptheria." 

That the prevalence of the disease depends quite as 
much on the condition of the inhabitants as upon the 
moisture or temperature of the atmosphere, or even 
upon the vague and indefinite " epidemic influence," so 
much talked of and so little understood, is shown by 
the following facts adduced by M. Trosseau : " In the 
villages of the Loire, remarkable for their salubrity 
and for their excellent position, I have seen diptheria 
prevail to a terrible extent, while the villages of 
Sologne, situated in the midst of marshes, remained 
exempt ; and, again, hamlets bordering on ponds de- 
populated by the epidemic, w T hile others enjoyed a 
complete immunity." 

And so, too, I have known the most malignant and 
putrid forms of typhoid fevers and of dysentery, and 
of erysipelas, and of scarlatina, as well as diptheria, 
prevail in the most salubrious places in New England 
and New York, and in as healthful localities, probably, 
as the sun ever shone upon. And there, as elsewhere, 
I suspect the essential causes are to be found chiefly 
in the habits of the people. The epidemic influence is 
within the vital domain itself, instead of the atmos- 
phere without. 

Dr. Samuel Bard, as well as nearly all the writers 
of the seventeenth century, considers the disease to be 
infectious. He says : " The disease I have described, 
appeared to me to be of an infectious nature, and as 
all infection must be owing to something received into 
the body, this, therefore, whatever it is, being drawn 



Infectiousness. 91 

in by the breath of a healthy child, irritates the 
glands of the fauces and trachea as it passes by them, 
and brings about a change in their secretions. The 
infection, however, did not seem, in the present case, 
to depend so much on any generally prevailing dis- 
position of the air as upon effluvia received from the 
breath of infected persons. This will account why the 
disorder should go through a whole family and not 
affect the next-door neighbor." 

Dr. Ranking, in his late lectures on diptheria, has 
probably presented the subject of its contagiousness or 
infectiousness in the true light. He remarks : " My 
own conviction is, that it is infectious to a limited 
degree ; by which I mean, that when patients are 
accumulated in small, ill-ventilated rooms, the disease 
is likely to be communicated ; but I do not fear that, 
like scarlatina or erysipelas, it may be propagated in 
spite of all sanitary precautions. Still less that the 
infection can be conveyed by the clothes or persons of 
those who visit or superintend the patients. That it 
commonly spreads through the family once invaded is 
to be attributed, in some degree, to the persistence of 
the same cause as originated the first case." 

Dr. Edward Ballard, of Islington, in an article pub- 
lished in the Medical Tim.es and Gazette, July 23, 
1857, adduces the following, among other facts, in 
support of the infectious character of diptheria : " In- 
fectious diseases habitually spread in families they 
invade. Out of forty -seven families there were only 
fifteen in which the other members all remained 
healthy. Of course it may be argued, in opposition, 
that all the members of a family are equally exposed 
to the operations of local causes of disease. As a rule, 
diptheria spread in the houses it invaded, chiefly 



92 DlPTHEEIA. 

among those members of the several families who 
were most closely in communication. In no case 
where separation from the sick person had been effect- 
ed early in the disease, have I noticed that it has spread 
to the separated individuals." 

Although we admit that persons affected with dip- 
theria may communicate, under favoring influences, 
the causes of the disease to others, it must be obvious 
that whatever local or other causes occasion it in any 
one member of a family, are also liable to induce it in 
all the rest, quite independently of contagion or infec- 
tion. And in point are the results of inquiries institu- 
ted in fifty-seven houses where fatal cases have 
occurred : " In more than half of these houses there 
was some defect in the sanitary arrangements, or in 
the surrounding conditions of the patient. In the 
greater number of the houses thus deficient, the fault 
was discovered in the state of the drainage." 

Per contra we have an equally formidable array of 
medical authorities who contend that diptheria is not 
infectious at all, and but feebly if at all contagious. 

M. Daviot, who has written a memoir on the dis- 
ease, declares that he has never met with an instance 
where it was communicated by personal intercourse ; 
and that neither the attendants nor those who cauter- 
ized the throats of affected children contracted the dis- 
ease. Negative testimony, however, should have but 
little weight against positive. What one physician 
has seen is not to be disproved by what another has 
not observed. A disease may be infectious or conta- 
gious, and prevail in different places and under differ- 
ent circumstances in the same place, epidemically, 
endemically, or sporadically. All persons who are 
brought in contact with patients affected with smalt 



Infectiousness. 93 

pox, measles, or syphilis, do not have the disease ; and 
it not unfrequently happens that only one person in a 
neighborhood will have small-pox, measles, whooping- 
cough, mumps, etc. 

Dr. Crighton, of Edinburgh, treated forty-five cases 
of diptheria, of which nine resulted fatally ; and in 
reporting the cases he remarks: " In only two cases 
was there anything like proof of contagion, and, 
from all that I have seen of diptheria, I believe that, 
although it would be incorrect to separate it from the 
list of communicable diseases, yet it is very feebly so 
compared with many others. I may mention one 
instance which struck me particularly, where, in a 
large family of six or seven children, and chiefly under 
the age of twelve, a child had the disease in a very 
severe form, and although he was never isolated during 
the day from the others, but lay on a sofa in a room 
where I generally found several of them at my visit, 
they all escaped." 

Dr. Monkton, of Kent, England, who has had a 
large experience in diptheria, reports through the Med- 
ical Times and Gazette of February 26th, 1857 : " JSTo 
decisive instance of the communicability of the disease 
has come before me ; on the contrary, I have seen it 
attack individuals only, in a family of liable persons, 
much more frequently than I think scarlet fever would 
have done. My own conviction is, that diptheria is 
epidemic, endemic (i. e., largely affected by locality), 
and non-contagious, or, if contagious at all, vastly less 
so than scarlet fever, from which it is very distinct." 

Dr. Slade remarks : " Now, although those who favor 
the idea of contagion find in the phenomena of cuta- 
neous diptheria strong ground for the support of the 
theory of inoculation, there are facts which would 



94 DlPTHEKIA. 

equally seem to oppose it. For example : it has been 
observed in these epidemics that the false membrane 
upon the skin not only presents itself in those not pre- 
viously affected with faucial diptheria, but it not un- 
frequently attacks remote parts, such as we should sup- 
pose were inaccessible to inoculation, as, for example, 
the folds of the groins in children, and the spaces be- 
tween the toes. A single well-observed fact of this 
kind is sufficient to cast a doubt on the theory of in- 
oculation." 

On the subject of the communicability of the dis- 
ease, Dr. Greenhow remarks : " Although I have no 
proof that diptheria is communicable by means of the 
exudation, many facts have fallen under my notice 
which convince me that the disease is in some way or 
other communicable. I attach little importance to the 
circumstance that diptheria so often attacks simulta- 
neously, or at short intervals, several members of the 
same family ; such facts may be explained on the sup- 
position that the patients have in such instances been 
all exposed to one common cause, be it endemic or epi- 
demic. But if, soon after the arrival of a patient from 
an infected district, diptheria should break out in a 
place where it did not previously exist, and attack per- 
sons who have been in direct communication with the 
invalid, and especially if it attack only such persons, 
then have we the strongest presumptive evidence of its 
being a contagious disease." 

The facts already adduced— and a multitude of 
similar ones could be easily collated — prove to my 
mind, most clearly, that diptheria originates indige- 
nously, and that it may be communicated, under pe- 
culiar circumstances, from one person to another. 



Causes. 95 



CAUSES OF DIPTHERIA. 

On no subject is medical literature more crude, 
vague, unsatisfactory, and irrational than in relation 
to the causes of disease. And this must ever be the 
case so long as the medical profession confesses pro- 
found ignorance of the essential nature of disease. 
When this primary problem is solved, when medical 
men understand what disease is, they will not be long 
in comprehending the causes which produce it, at least 
with sufficient accuracy and exactitude for all practical 
purposes. 

For hundreds of years the profession, in its investi- 
gations of the causes of disease, the nature of disease, 
and the remedies for disease, has been pursuing a mere 
phantom. Medical men have assumed that diseases 
have specific characters or natures inherent in them- 
selves, and that therefore each must have a specific 
cause, and require a specific remedy. There can be 
no greater delusion. And when we reflect for a single 
moment that disease — that all disease — is the action 
of the living system to resist poisons, expel impurities, 
or to repair damages ; that it is purely and simply a 
defensive or remedial struggle — vital action in relation 
to things abnormal — this whole doctrine of specifics 
will appear sufficiently absurd. 

There are but two sources of disease, aside from me- 
chanical injuries or irritants, and there are, as was ex- 
plained by Hippocrates nearly three thousand years 
ago, poisons introduced from without, or impurities 
generated within. If we inhale miasms or particles 
of foreign substances which float in the atmosphere, 
or if we absorb them through the skin, or if we take 



96 DlPTHERIA. 

them into the stomach in the shape of aliments, condi- 
ments, or medicines, the blood becomes impure and 
the capillary vessels obstructed. Or if the waste or 
effete matters of the system — the ashes or debris of the 
disintegrated tissues — are not properly deterged by the 
various emunctories, impurities are ingenerated ; that 
is to say, the effete matters which should have been 
expelled are retained, causing obstructions, and thus 
becoming the occasions or causes of disease ; the dis- 
ease itself, let it never be forgotten, is the effort of the 
living system to remove these obstructions. 

The particular form of disease, the manner in which 
the remedial effect, or the process of purification will 
be manifested, must depend on a variety of circum- 
stances and conditions — the nature and quantity of the 
obstructing materials, the absolute and relative vigor 
and integrity of the various depurating organs, the 
habits of the patient, atmospheric, electrical, thermo- 
metrical, and passional influences, etc. 

"We are taught in medical books that certain diseases 
have inherent dispositions or tendencies to impress or 
act upon particular parts of the system, or to locate in 
certain organs, or to seat themselves here or there, or to 
run through the system, etc., etc., all of which vaga- 
ries are founded on a false notion of the nature of 
disease. 

Dr. Jacob Bigelow, of Boston, who claims the honor 
of being the father, or at least one of the fathers of the 
modern doctrine of " self-limited" diseases, gives us, 
in a late work (" Nature in Disease") the following 
lucid exposition of the subject : " By a self-limited 
disease, I would be understood to express one which 
receives limit from its own nature, and not from foreign 
influences ; one which after it has obtained a foothold 



Causes. 97 

in the system, can not, in the present state of our 
knowledge, be eradicated or abridged by art." 

If disease is really an independent entity, a thing, 
a foreign substance, a something outside of the living 
organism, a being or creature analogous to a ghost or 
goblin, imp or sprite, fiend or demon, spook or spirit, 
such reasoning might be the very quintessence of med- 
ical philosophy. But if disease is in fact nothing of 
the sort ; if it be the exact contrary, if the disease and 
the vis ?nedicatrix naturce be one and the same thing, 
as I hold to be true and demonstrable, then, in the 
light of this truth, nothing can be more ridiculously 
nonsensical than Dr. Bigelow's explanation of a self- 
limited disease. Disease is represented, by the learned 
Doctor, as a creature or thing which has obtained a 
" foothold" in the system, and after having established 
itself in the vital domain, it then ordains for itself 
a law of limitation, and receives limits from its own 
nature. Is there not something incomprehensibly 
queer in the idea of a disease taking forcible posses- 
sion of a living body, then dictating to itself laws and 
limits, affixing to itself boundaries of time and space, 
selecting the place of its abode, and determining just 
how long it will stay or go, or exist, or remain, or run, 
or be seated,. or where, and when, and how, and why 
it will consent to be unseated, and utterly refusing to 
be " eradicated or abridged" by the art of dealing out 
all the drugs of the apothecary shop ? 

The error lies further back. It consists in mistaking 
the relations of living and dead matter. Medical 
books and schools teach that the causes of disease act 
or make impressions on the living organism, and that 
diseases do the same, and that remedial agents do 
the same. The reverse of all this is the truth, as 

5 



98 DlPTHEKIA. 

taught in the Book of Nature and in the School of the 
Universe. 

As a general statement, poisons, impurities, or or- 
ganic lesions are the direct or immediate causes of 
all diseases, and unphysiological habits or conditions 
are the causes of these causes— the remote or predis- 
posing causes of disease. But it is very difficult to 
detect the nature or properties of those poisons or im- 
purities — morbific materials — which result from the 
changes, transformations, and decompositions of or- 
ganic matter. They elude all the art of the chemist, 
all the skill of the anatomist, and defy the vision of 
the microscopist. An almost inappreciable quantity 
of variolous matter, for example, applied to any part 
of the living body denuded of its cuticle, will occasion 
a violent fever attended with a pustular exanthema over 
the whole surface ; yet the analytical chemist has never 
been able to ascertain the constituent elements of that 
virus. And, indeed, chemistry never has been and never 
will be able to determine the exact composition of any 
organic product, whether it be food, tissue, effete mat- 
ter, secretion, excretion, poison, or virus, for the reason 
that, in the process of analysis, some of the elements 
are changed or lost. Chemistry can determine what 
remains as the result of the analysis, and this is all. 
And when chemists undertake to tell us what food is, 
what disease is, what vitality is, what living tissue is, 
or what remedies are, by a process of chemical analy- 
sis, they are entirely out of their proper element. 
These problems are all to be determined by physiologi- 
cal laws, not by chemical decompositions ; by the in- 
* stincts of the living organism, and not by the constitu- 
tion of dead matter. 

In croup, and in diptheria, and in certain other mor- 



Causes. 99 

bid conditions of the system, in the process of depu- 
rating the system of its virus or impurities, the fibri- 
nous or albuminous elements of the blood are exuded 
upon the skin or upon the mucous surfaces ; in cholera, 
the serum of the blood is poured into the intestinal 
tube ; in eruptive fevers, some morbific material is ex- 
pelled through the skin ; in diabetis, a saccharine ele- 
ment is deterged copiously through the kidneys ; in 
diarrhea, fecal matters are dejected by the bowels; in 
consumption, tuberculous matter is expelled through 
the pulmonary structure; in cholera morbus, vitiated 
and acrid bile is excreted from the liver; in simple 
fevers, effete matters of various kinds are determined 
with more or less force to one or more of the depurat- 
ing organs, etc. In all of these cases — and the princi- 
ple applies to all diseases — the form of the disease and 
the nature of the material excreted or expelled, de- 
pends on — 1. The force and direction of the remedial 
effort. 2. The organ or structure through which the 
purifying process chiefly takes place. 3. The condi- 
tion of the whole mass of blood at the time. 4. The 
quantity of morbific material to be eliminated ; and 
5. The external influences operating, so to speak, at 
the time, as temperature, humidity, etc. 

Much has been said and written on the influence 
which meteorological and cosmic conditions exert in 
the production of cholera, diptheria, and other pesti- 
lences ; but the whole subject is scarcely better under- 
stood now than it was before the sciences of meteor- 
ology and cosmogony were heard of. Bretonneau 
entertains the notion, that diptheria could only be de- 
veloped in a damp atmosphere. But in the recent 
epidemics of France and England, the disease has pre- 
vailed in high and dry situations. And in this country 



100 DlPTHERIA. 

I am not aware of any facts which tend to prove that 
it is more prevalent or more severe in damp localities 
than in dry. In California, noted for its very dry. 
summer atmosphere, according to Dr. "Wooster, the 
disease has been very prevalent and very fatal. Dr. 
Wooster states, in a monograph on diptheria : 

"In our climate, the air in summer becomes so dry, 
that if an ordinary soft wooden pail or bucket be half 
filled with water, and set in the sun in the open air 
for six hours, and then two quarts of water be added, 
it will leak through the joints of the shrunken staves, 
above the surface of the first portion of water. A 
miner uses a bucket to bail water from a hole all the 
forenoon, and, although it is perfectly saturated with 
water, yet if he leaves it in the sun while he goes to 
his dinner, when he returns it will often fall to pieces 
as he attempts to take it up. 

" This is the kind of air in which the disease has oc- 
curred with unequaled fatality in this State. In this 
city I can not ascertain that a case has occurred in that 
part of the town built over or near the waters of the 
bay, or on the salt marshes near it. But I have seen 
cases in the high part of the city, and on bluff head- 
lands extending into the bay, points that from their 
elevation and constant exposure to a strong breeze 
would be thought inaccessible by any morbid [mor- 
bific ?] effluvia." 

It should be considered here, that the inhabitants of 
high and dry situations may live in the line of the 
currents of wind which convey the miasms of the low 
and wet localities, and hence, although their situations 
are in themselves perfectly salubrious, the people resid- 
ing there may be really more exposed to miasmatic 
diseases than are the people who dwell in the more hu- 



Causes. 101 

mid atmosphere of the lowlands, out of the direction 
of the prevailing winds. 

According to Mr. Ernest Hart, the diptheria has ap- 
peared in France and in England with no regard what- 
ever to any recognized climatic or meteorological laws. 
It has visited the open hamlets of the rural depart- 
ments, and the crowded courts of the great cities ; it 
has prevailed at the sea-side ; in the heat of summer ; 
during the cold of winter ; in marshy, ill-drained local- 
ities ; in dry and elevated regions ; in ' ill-ventilated 
barracks, and in the open country; in dry places; in 
damp places ; in the low valleys, and on the high 
mountains. 

There is truth — practical truth — in the following 
paragraph : " Zymotic in its nature, it tends to fasten 
upon whomsoever is debilitated by previous disease, 
or by a constitution naturally feeble and artificially 
effeminized, or where vitality is lowered by the de- 
pressing influences of luxury, indolence, and inactiv- 
ity ; and the habitual defiance of physical and hygie- 
nic laws, which is so frequent an element in fashion- 
able life. Hence individual cases come into play, and 
introduce this associate of the poor into the palaces 
and mansions of the great, which they so often fringe. 
Diptheria finds there its victims pale and anemic, or 
grossly sanguineous and unhealthily excited." 

" Grossly sanguineous 1" Bad blood is the essential 
condition of all putrescent, pestilential, and malignant 
diseases, and gross living is the essential cause of bad 
blood. And when we investigate the etiology of dip- 
theria to its starting-point, I suspect we shall find that 
impure or indigestible food, with inattention to per- 
sonal cleanliness — the chief sources of impure blood 
and foul secretions — are the essential causes of diptheria. 



102 DlPTHERIA. 

Nor can I forbear alluding in this place to what I 
can not help regarding as standing at the very head 
of the " specific" causes of this disease — swine raising 
and pork diet. That the flesh and grease of that fil- 
thy scavenger, the hog, in the form of pork, ham, sau- 
sages, lard, etc., constitute a most impure and blood- 
poisoning aliment, I believe no intelligent physiologist 
will deny. And that a sty-fed hog is a diseased car- 
cass, is evident to all pure senses. That pork and 
scrofula stand to each other in the relation of cause 
and effect, has been proverbial among observing men 
for centuries. Yet all over this Christian land some 
form of sty-fed and sty-fattened hog-food is one of the 
most common, most cherished, and most relished 
dishes to be found on the tables of the rich or poor ; 
while in an ordinary hotel, boarding-house, or restau- 
rant, or even in a private family, but few articles of 
food can be found not attainted with some part or por- 
tion of the tissue or adipose matter derived from this 
disgusting animal. 

Within a few months I have visited and lectured in 
different States — Maine, Massachusetts, Illinois, Indi- 
ana, Iowa, Ohio, and in the District of Columbia — and 
in all places I inquired particularly as to the preva- 
lence of diptheria, and also as to the dietetic habits of 
the people, especially with regard to pork-eating. In 
each State which I visited I heard of places where the 
disease had been very prevalent and very fatal, and in 
all of these places swine-food was employed very free- 
ly, as was swine-grease, as shortening for pastry, cakes, 
biscuit, and even bread. 

But pork-breeding as well as pork-eating conduces 
to this as well as to other foul and malignant epidem- 
ics. And I am of opinion that all of the contagious 



Mortality. 103 

diseases in the world originate from slaughter-houses, 
hog-pens, distilleries, barn-yards, stables and henneries, 
provision depots, etc., where animal offal and excre- 
ments accumulate, and where animal matter is con- 
stantly undergoing decomposition and putrefaction, 
thus loading the atmosphere with miasms and impuri- 
ties. If the people would all become vegetarians, there 
would be, in my opinion, an end at once of such dis- 
eases as eruptive fevers, and of contagious diseases of 
every sort. 

Persons who do not eat pork, but who dwell in 
close proximity to piggeries, may become infected 
with the seeds of diptheria or some other foul disease. 
The very atmosphere is poisoned with the effluvia 
which constantly emanates from the lungs and skin and 
excrement of the animal, so that one who abhors the 
unclean aliment may be destroyed by inhaling the 
miasms which the noxious animal generates, as one 
who does not smoke cigars nor chew tobacco maybe 
nauseated and sickened by the breath and atmosphere 
which are rendered poisonous and pestilential by those 
who do smoke and chew. 

MORTALITY OF DIPTHERIA. 

The mortuary statistics of no disease present greater 
diversity of results than those of diptheria. This may 
be accounted for, in part, by the great diversity of cir- 
cumstances under which the disease prevails, and the 
different habits and constitutions of the persons who 
are the subjects of it. Much, however, is due to the 
course of medical treatment adopted. And I fear 
that a careful investigation of this branch of our sub- 
ject would disclose another evidence of the truth of 



104: DiPTHERIA. 

the saying, " Just in the ratio that doctors and drugs 
have increased, diseases and deaths have multiplied." 
So far as I have been able to collect statistics bearing 
upon this point, I find no exception to the general rule, 
that the mortality of diptheria is everywhere in pro- 
portion to the potency of the drug-medication. 

As is the case with malignant scarlet fever, croup, 
typhoid pneumonia, and other diseases of low diathe- 
sis, many cases will hear drug-treatment, bleeding, 
blistering, etc., which are not benefited by them, 
while in the most severe cases their administration is 
almost certain death. Physicians have often noticed 
and recorded the fact that, in the treatment of scarla- 
tina maligna, a single dose of castor-oil, or a moderate 
bleeding, has destroyed the life of a patient in a few 
hours. But in the milder form of this disease — scar- 
latina simplex — the patient will bear repeated bleed- 
ings and purgatives, and survive both the disease and 
the medication. These remarks apply with equal 
force to diptheria. The discordant methods of prac- 
tice to which different physicians have resorted, and 
the disagreements of medical men of extensive observ- 
ation and large experience, with regard to what is 
useful or injurious in its treatment — some authors con- 
demning as aggravating the disease and endangering 
the life of the patient the very remedies and measures 
which others rely upon as essential to the cure — render 
an estimate of the necessary or even actual mortality 
of the disease itself, independent of treatment, a very 
difficult matter to determine. In their reports of cases, 
medical men almost universally assume that all patients 
who recover are indebted for their lives to the drugs 
and doses administered by the physician. But this is by 
no means a logical conclusion. It may be that patients 



Mortality. 105 

recover in spite of the medicine, rather than with its 
assistance. And this I believe to be the general if not 
the universal rule, so far as drug-medication is con- 
cerned. Medical reasoning is unlike all other reason- 
ing. It seems to disregard all the ordinary rules of 
logic ; and medical men have a method of ratiocination 
peculiarly professional and exclusively medical. They 
claim that their remedies have a power over the vital 
functions, and that they are capable of controlling 
morbid actions ; and when a patient recovers, the 
remedies employed are accredited with the cure. But, 
suppose the patient dies ? what then ? Do these med- 
ical logicians charge the hilling to the medicine ? 
Never. The patient dies in spite of it. This is not legit- 
imate logic. It is just as rational to assume that when 
the patient dies, the medicine hills him, as to assume 
that when the patient recovers, the medicine cures him. 
Indeed, this is the more reasonable assumption, because 
the relation of the drug to the living organism is that 
of a poison ; its tendency is to kill. 

These views are corroborated by the observations 
which I have had the opportunity to make in various 
parts of the country, with regard to the results of 
Hygienic and of drug treatment. In all cases where 
little or no medicine was employed, the per centage of 
deaths was very small. In all cases where active drug 
treatment was resorted to, the proportion of deaths was 
large. In some places where the disease has prevailed 
endemically, every case has been treated hygienically, 
without the loss of a single patient ; while in other 
places, all the cases have been treated with the ordinary 
drug remedies, and all have died. 

These extreme results surely mean something ; and 
before we can determine diptheria to be a dangerous 

5* 



106 DlPTHERIA. 

disease, per se, we must understand the effects of the 
various methods of treatment brought to bear upon it, 
or upon the patient. 

"While lecturing in Boston, recently, I met with Dr. 
Prescott, of Farmington, Me., who, after an experience 
of forty years of drug-medication, came to the same 
conclusion that Prof. Jos. M. Smith, of the New York 
College of Physicians and Surgeons, has recently 
arrived at, that " drugs do not cure disease ; disease 
is always cured by the vis medicatrix natures /" and to 
the conclusion that Prof. Alonzo Clark, of the same 
school, not long since announced to the medical class, 
viz. : " All of our medicines are poisonous, and, as a 
consequence, every dose diminishes the patient's vital- 
ity ;" and who, acting in accordance with his honest 
convictions of truth and duty, renounced drug-medica- 
tion and adopted the Hygienic, which system he has 
advocated and practiced ever since. 

Dr. Prescott informed me that in one of the adjoin- 
ing towns, of thirty-five cases of diptheria, thirty 
terminated fatally. Of course these cases were treated 
with the ordinary remedies. Dr. Prescott has himself 
treated several cases hygienically, and has lost but one. 
In October last, I visited and lectured in Augusta and 
in Yassalboro', Me., and there learned the statistics of 
the mortality of the disease as it had prevailed in 
various parts of the State. The whole number of 
deaths was about one half of all the cases, although 
the mortality varied in different places from twenty to 
seventy-five per cent. In one town — Canton, if I 
recollect — of twenty cases, sixteen were fatal. In a 
few instances the friends of the patients had managed 
the cases as well as they could with " water-treatment," 
and of these none were lost. During a lecturing ex- 



Mortality. 107 

cursion in December and January last, in some parts 
of Ohio, Indiana, Illinois, and Iowa, I heard of many 
places in which the disease had appeared, and the 
average mortality was nearly the same as in New 
England. In some places nearly all the patients died, 
and in other places a very small proportion of the 
cases were fatal. In Sullivan County, N. Y., where 
the disease prevailed endemically, as I have already 
remarked, all the cases terminated fatally. And in 
Orange, Conn., according to the report of the attending 
physician — Dr. Beardsley, of Milford — of the fifteen 
cases which occurred, fourteen were fatal. And it 
may not be irrelevant to remark that, being on a pro- 
fessional visit in the neighborhood of Orange, soon 
after the occurrence of the endemic in the place, I was 
informed that the fifteenth case — the only patient who 
survived — removed from the place, and from the 
Doctor, so soon as the disease attacked him. What 
relation this circumstance had to the recovery is, of 
course, a legitimate question for differences of opinion. 

Dr. Fougeaud, in a monograph on a terrible 
epidemic which prevailed in San Francisco, and in 
other towns in California in the autumn of 1856, hav- 
ing all the characters of pharyngeal diptheria, states 
that the mortality was appalling. " Few children 
attacked by it recovered." 

In the city of New York no record of death of dip- 
theria is to be found anterior to 1857, and in that year 
only two cases are recorded. In 1858 only five cases 
were reported to the Inspector's office. In 1859 the 
cases had increased to fifty-three, and in 1860 four 
hundred and twenty-two deaths were reported ; since 
which the mortality has averaged about fifteen per 
week. 



108 DlPTHERIA. 

During the last two years, newspaper accounts have 
come to us from more than a hundred places in the 
United States, stating that families had lost three, 
four, five, six, seven, and even more members of the 
disease, and in not a few instances all of the members 
of the family have died. And during this time I have 
received some hundreds of communications, asking 
for information respecting the proper Hygienic treat- 
ment of the disease, of whose nature and contents the 
following extracts will serve as samples : 

Lacon, Illinois, Nov. 28, 1860. 

R. T. Trall, M.D. — Dear Sir : Diptheria is raging 
all around us. All ages are having it. With children 
it is very fatal — all, in fact, die. The people in this 
community are most completely blinded by drug- 
opathy, and are doctored in what seems to my com- 
mon sense to be the most outrageous manner — blisters, 
turpentine, quinine, brandy, beef-tea, etc., etc. I have 
read what you have written on the subject in the Wa- 
ter-Cure Journal. Myself and wife have been among 
it constantly, and so far we keep well, as do our five 
children. S. S. H. 

Sandwich, Mass., Jan. 16, 1861. 

Dr. Trall — Dear Sir : The diptheria has made its 
appearance on all sides of us, but has not yet entered 
our village, though a widow lady, who moved from 
our town some months since, has lately brought here 
for interment the remains of four children, the victims 
of the new disease. Under the circumstances, I very 
naturally feel a little anxious for my only child, a boy 
of nine years of age, for, should he be attacked with 
the disease, I should be very loth to subject him to the 
tender mercies of the regular system of practice. I 



Mortality. 109 

wish to treat him hydropathically should occasion re- 
quire, and to that end I desire such information and 
advice as you can give me. I should perhaps state 
that I am a humble mechanic, yet I trust with suffi- 
cient common sense to understand the rationale of wa- 
ter-cure ; for, guided by the instructions of your " Hy- 
dropathic Encyclopedia," I have been able for several 
years to dispense entirely with drug-medicines, and 
with the advice of physicians. 

The reports of physicians who claim remarkable 
success in the treatment of diptheria should be taken 
with some grains of allowance, for it not unfrequently 
happens that when throat-affections are numerous, 
with occasional or sporadic cases of membranous exu- 
dation, all will be grouped together under the head of 
diptheria ; and for this reason it is exceedingly diffi- 
cult, in many cases, to judge of the merits or demerits 
of the treatment adopted. Some physicians have 
claimed unusual skill, or a superior methodus medendi, 
because they have lost less than ten per cent, of the 
cases they have treated ; but it is not certain that, had 
there been no physician in the case, even the ten per 
cent, of mortality might not have been diminished. 

Professor Alonzo Clark, in his recent lectures on 
diptheria, in relation to its mortality, remarks : 

" We now turn to the mortality of diptheria. This 
is a complex problem. Its fatality in its different oc- 
currences and in different places varies more than that 
from any other disease I can name to you. In certain 
families, schools, and villages, the deaths among those 
attacked are more numerous than from any other epi- 
demic affection. The proportion is not less than that 
from membranous croup or tuberculous meningitis. 



110 DlPTHERIA. 

Under other circumstances, no more than one case in 
forty or fifty proves fatal. But this remarkable differ- 
ence, while there is really the membranous inflamma- 
tion, is less embarrassing than the fact that many phy- 
sicians, who have reported their observations, have not 
separated their cases of simple tonsillar inflammation 
without any pellicular exudation, from those of true 
diptheria ; but on the contrary, professing to regard 
the two affections as arising from the same cause, since 
they prevail at the same time, have grouped them to- 
gether, and so have greatly reduced their proportion 
of mortality. I have already said that there is but 
one way of treating this matter fairly. It is to make 
the membrane the basis of classification. This will 
separate diptheria from everything but the true croup ; 
and the marks soon to be indicated will commonly be 
sufficient to establish the distinction between these. 
Indeed, the epidemic character of one and the sporadic 
occurrence of the other will, of itself, be enough, at 
least in the great majority of instances. It may be 
said that this distinction between simple and dipthe- 
ritic sore throat is not scientific. It may be so ; but it 
is better than scientific, it is practical. The aim and 
end of science is the improvement of man's condition. 
If this improvement can be but attained by dividing 
into two groups w 7 hat Nature allows us to class as one, 
no rule of sound reason can forbid the separation. 
Besides, science does require us to make distinctions 
when there are differences. And here we have the 
broad difference that one disease is ephemeral, with a 
uniform tendency to recovery ; the other is often terri- 
bly fatal, or it is liable to a long train of sequences of 
a serious, if not of an alarming character. 

" An example will enable you to understand how far 



Mortality. Ill 

I would have you cany the distinction. Five children 
in one family had sore throat, all occurring within the 
same week. The same cause had probably operated 
on all, but the effects resulting from that cause were 
different in the different children, and the difference, 
no matter how produced, was cardinal so far as the 
safety of these patients was concerned. Three of them 
had active fever, flushed face, pain in swallowing, the 
tonsils were swollen and red, and on the anterior and 
inner surface of each were half a dozen or more yel- 
lowish white spots. The matter constituting these 
spots was an opaque concretion from the follicles of 
these organs, and each mass was nearly globular in 
shape, and was embedded in the tonsil. To a person 
not familiar with their appearance, they might have 
been mistaken for false membrane ; but they were 
rounded, and the false membrane is flat; they were 
yellowish-white- — the membrane is very rarely, if ever, 
of this color ; they were isolated — the membrane forms 
at separate points, without coalescing, only in excep- 
tional cases. These all recovered after three or four 
days, and their condition excited no apprehension for 
their safety so long as the diseased action went no fur- 
ther. The two other children had ash-colored mem- 
branous patches on the tonsils. In one, the membrane 
did not extend beyond the fauces, and although it fell 
off and formed again, the sickness was not very grave, 
lasting about ten days. In the other it penetrated into 
the larynx and proved fatal in three days. A physi- 
cian's pride is in his cures, yet you may not be tempt- 
ed to say, under parallel circumstances, that you had 
five cases of diptheria and lost but one of them. 
There were but two cases of diptheria. A physician 
reports that he has seen two hundred cases of dipthe- 



112 DlPTHKRIA. 

ria, and has lost only three or four per cent. Another 
physician practicing in the same city, in the same epi- 
demic, in the same class of society, and adopting the 
same general plan of treatment, has seen a hundred 
cases, and has lost thirty per cent. The latter states 
that he only counts the instances of membranous dis- 
ease ; the first considers his cases all diptheria, but 
does not saj 7 that membrane is his test. TTould you 
not be compelled to hesitate before you admitted these 
two reports into the same generalization ? Physicians 
who have had extraordinary success, should tell us in 
so many words, that all their cases, or if not all, how 
many, exhibited the membrane. Tou will not find 
this precision when you wish to ascertain, on a large 
scale, the law of mortality. Thus then is this problem 
complicated. But we must do the best we can with 
the material within our reach. 

" From the i Medical History, General and Particu- 
lar, of Epidemic, Contagious, and Epizootic Diseases 
in Europe, from Remote Times to our own Days,' by 
Ozanam (vol. iii. p. 279), we learn that, so far as he 
could ascertain the facts, the mortality of thirty-nine 
epidemics of what is now regarded as diptheria, be- 
tween 1559 and 1S05, was as high as eighty in the hun- 
dred of those attacked. The Commission of the 
French Academy of Medicine (Martin Solon, and 
others) reported in 1833, that, in the French epidemics 
from 1771 to 1830, the deaths among those attacked 
by croup very often complicated with gangrenous an- 
gina, were as one to four ; among those attacked by 
angina, membranous and gangrenous, simple or com- 
plicated, there was the same mortality, that is, one in 
four. ('Mem. Acad.,' vol. iii. p. 429.) Trosseau 
found, when pursuing his inquiries regarding cutane- 



Mortality. 113 

ous diptheria, that in some families and hamlets fright- 
ful havoc had been made by the throat disease. In 
one family seven children had been attacked, and six 
died. In one hamlet ten in twelve had died ; in an- 
other nineteen in twenty-one. Dr. Thayer (Berk's 
Medical Journal) states that Dr. Beardsley had in 
Orange, Conn., among the pupils of a school, and in 
three families where the pupils boarded, fourteen deaths 
in fifteen cases. In the military school spoken of by 
Bretonneau, and referred to under the head of conta- 
gion, four deaths had occurred in as many cases, when 
the system was adopted of examining the throats of 
all the pupils daily ; by this means sixty cases were 
seen at the commencement of the disease, and all were 
successfully treated ; the mortality was thus, including 
a nurse that died, one in thirteen. Daviot states (' Me- 
morial on Diptheria,' p. 363) that in the years 1841-2 
-3-4, he treated four hundred and sixty-one cases, and 
that he had forty deaths, a mortality a little better 
than one in eleven. Dr. Willard, in giving a history 
of the late Albany epidemic (N. Y. State Med. Soc. 
Trans., 1859), feels authorized to reckon the cases in 
that city at two thousand, and the deaths as one hun- 
dred and eighty-eight, the ratio being one to about ten 
and a half. Dr. Kneeland (Am. Med. Times, Jan. 26, 
1861) living in the central portion of this State, ascer- 
tained that among eighty persons attacked in his neigh- 
borhood ten died, or one in eight. Among the facts 
collected by Dr. Thayer are the following : six cases 
in Pittsfield, Mass., and three deaths, one in two ; 
twenty-four cases reported by Dr. Bostwick, of Red 
Rock, N. Y., and live deaths, one in five / eighty-one 
by Dr. Meacham, of West Stockbridge, Mass., and 
eight deaths, one in ten nearly ; one hundred and tliir- 



114 DlPTHERIA. 

ty-six by Dr. Wells, of Menomonec, Wis., and four 
deaths, one in thirty-four j eighty-five cases by Dr. 
Lawrence, of North Adams, Mass., and no death ; 
' forty or fifty' cases by Dr. Holmes, of South Adams, 
and no death. Dr. Jacobi, of this city, says {Am. 
Med. Times, Aug. 18, 1860), ' Of five hundred cases, 
we believe that we have lost not more than thirty,' 
about one death in seventeen cases. Dr. Watson, in a 
paper read before the New York Academy of Medi- 
cine, and published in the Aon. Med. Times, states 
that of one hundred and forty-eight cases treated by 
himself, only two proved fatal, one in seventy-four ; 
and in one hundred that he saw in the practice of 
other physicians of the city only four died, one in 
twenty-five ; in all together about one in forty-one. 
Dr. Woodward, of Brandon, Vt , and his neighbor, 
Dr. O'Dys {Am. Med. Times, Dec. 5, 1860), treated 
thirty eases each, without a single death, and Dr. 
Woodward is careful to state that his cases were all 
true diptheria. In an adjoining town, where the dis- 
ease occurred before it reached Brandon, he says al- 
most eve?y case was fatal. Statements that vary so 
widely as these do can not be usefully generalized. 
If they all relate to the same type of disease, they 
show the impossibility of applying a general average 
to particular epidemics. My own opportunities of see- 
ing the affection force upon me a great mortality ; but 
from what I have seen, and chiefly from what active 
practitioners here tell me, without any attempt at nu- 
merical computation, I should set down the deaths in 
New York among those having the membranous dis- 
ease, including membranous sore throat in scarlet fever, 
as one in six or eight. But these conjectural estimates 
are worth very little. Indeed, accurate statistics will 



Mortality. 115 

not avail much in informing you what to look for in 
any commencing or expected epidemic. I have al- 
ready told you this, and I repeat it here because I wish 
you to be fully aware of the varying types of the dis- 
ease. In reviewing what has just been said, you no- 
tice that, while in one place there is not a single death 
among sixty persons attacked, by what the writer as- 
sures us is true diptheria, in an adjoining town it de- 
stroyed nearly all whom it touched. This difference 
you may ascribe to different plans of treatment. I 
can not say it was not so in that instance. But you 
will hear it said that the disease is very grave in one 
place, and very mild in another ; that the earlier cases 
in a school, hospital, or town are attended by a greater 
mortality than those which occur later in the epidemic. 
This is doubtless true, and it is true often because the 
type of the disease is different even in adjoining towns, 
and because its character changes as the epidemic ad- 
vances. I am told by a leading physician of Massa- 
chusetts, that in a town within the range of his consul- 
tation practice, nearly every case is fatal, not by the 
direct effects of the membrane, but by prostration and 
collapse, without a sign of dyspncea or cyanosis ; while 
in another village five miles distant the disease has the 
characters of an open inflammation, from which the 
mortality is comparatively inconsiderable, and when 
death occurs it is almost always caused by laryngeal 
and tracheal obstruction through the extension of the 
membrane from the fauces. I have already quoted 
statements coming from two physicians of that same 
county, that they have treated one hundred and twen- 
ty-five cases without a single death, both saying that 
the disease was very mild (but neither of them saying 
that it was characterized by a membrane)." 



116 DlPTHERIA. 



COMPLICATIONS. 



Among the numerous complications which are said 
to attend diptheria, authors mention sthenic or high 
fever ^ and typhoid or low fever. I must dissent from 
both of these propositions. The truth is this. The 
diathesis of the disease is essentially low or atonic, and 
hence can never have high or sthenic fever, neither 
as a part of the malady, nor as an accompaniment, nor 
as a complication. But as the disease is essentially 
febrile, and of low diathesis, and of continued type, it 
is always typhoid, so that this is an accompaniment 
and not a complication. The error of medical men 
consists in limiting their idea of fever to preternatural 
heat of the surface, and in mistaking a violent disturb- 
ance for strength of action. A fever, properly so 
called, consists of cold, hot, and sweating stages, these 
together constituting the paroxysm ; and in all fevers 
excepting the ephemeral type, which lasts but one clay, 
there is a succession of paroxysms ; and this succession 
of paroxysms is the foundation for the nosological 
arrangement of fevers into intermittent, remittent, and 
continued types. But in many cases of low fevers the 
hot stage is so slight as to be scarcely appreciable, 
and the careless observer may regard the case as non- 
febrile. When the heat of the surface is more consid- 
erable, yet slight and not uniform, the term " feverish- 
ness" is generally applied, or the " type" of the fever is 
said to be typhoid. And when the whole surface is 
preternaturally and decidedly hot, the fever is very 
apt to be confounded with entonic diathesis. But, as 
already explained, the disease is always febrile, and 
the fever, as well as the local inflammation, is always 
atonic and typhoid. 



Complications . 117 

It is true that diptheria may supervene in the course 
of a simple typhoid fever; but more frequently it 
happens that the diptheritic exudation of the local 
inflammation does not appear until the constitutional 
symptoms which constitute the fever have been man- 
ifested for one or two weeks. The following cases, 
mentioned by Dr. Clark, in his lectures on this disease, 
are in point : 

" Among the specimens of diptheria exhibited to 
you the present session, you will remember the tonsils, 
uvula, larynx, trachea, and fine divisions of the bron- 
chial tubes of an adult lined by false membrane. The 
patient from whom the specimen was taken had been 
suffering from typhoid fever for two weeks at the New 
York Hospital, when he was attacked with symptoms 
of croup, and died in a few days, tracheotomy having 
been unsuccessfully performed. Several cases of a 
similar character were seen at the same hospital during 
the epidemic of typhus some years ago, in patients 
affected by that disease. It seems to have occurred in 
these cases after the completion of the second week of 
the fever. M. Louis (' Arch. Gen. de Med., 5 torn, iv., 
1824) has reported two cases of membranous exudation 
in the air-passages, and the usual symptoms of dip- 
theria in patients having typhoid fever. One was a 
person twenty-three years old, who had been fourteen 
days in the hospital before the symptoms of the mem- 
branous disease began. The other was in a boy aged 
fifteen years. Dr. Greenhow (' On Diptheria ' p. 76) 
reports that Dr. Heslop, of Birmingham, found in 
Nov., 1858, that of four cases of typhus fever occur- 
ring in one house, two of the patients had membranous 
exudation in the throat. In one of these it is stated 
that the patient, a girl aged seven years, had suffered 



118 DlPTHERIA. 

nearly a fortnight before the appearance of the throat 
affection. In the other case the time of the occurrence 
of the latter is not mentioned. M. Louis' cases are 
described under the title, croup in adults ; but as dip- 
theria was prevailing in Paris at the same time, it is 
more reasonable to refer them to this class." 

Albuminaria has recently attracted the attention of 
physicians as a complication of diptheria. Says Dr. 
Slade : " An element in the nature of diptheria is of 
recent discovery. We allude to the presence of albu- 
minous urine in the disease. The first observation 
upon the relation of albuminaria to diptheria appears 
to be referable to a case reported by Mr. Wade, of 
Birmingham, to the Queen's College Medico-Chirur- 
gical Society, in December, 1857, and afterward pub- 
lished in his ' Observations on Diptheria.' Shortly after 
this, during researches on this disease at Paris, M.M. 
Bouchut and Empis made a similar discovery. Albu- 
minaria did not exist in every case examined, but it 
was seen in twelve cases out of fifteen. Both of these 
authors attach great importance to this renal compli- 
cation, as affording an anatomical explanation of the 
cause of death, when this can not be attributed to 
either of the other modes, viz., death by asphyxia or 
general poisoning." 

It seems to me that albuminaria can hardly be " an 
element in the nature of diptheria" unless it is invari- 
ably present ; and if so it would be an essential part 
of the disease, and not, in any sense, an accident or 
complication ; nor can I see the necessity for this 
" anatomical [pathological ?] explanation" of the cause 
of death, when the patients do not die of a asphyxia or 
general poisoning," so long as exhausted vitality is a 
sufficient cause of death in all cases. 



Complications. 119 

Other authors, however, have not found the compli- 
cation of albuminous urine except in rare instances, 
and when present, they do not regard it as materially 
affecting the result. Prof. Clark, whose attention was 
some time since called to this subject, has only found 
albuminaria as an occasional accompaniment, and does 
not regard its occurrence as in any manner varying 
the prognosis. 

Diarrhea, as we have seen, sometimes precedes and 
occasionally accompanies the diptheritic affection of 
the throat ; and in some instances it attends the later 
stages of the malady, when it is regarded as an accident 
or complication. It is always a serious occurrence, as 
it indicates great exhaustion of the vital powers, and, 
consequently, danger. 

Vomiting is regarded by some authors as a diag- 
nostic symptom, and by others as an incidental occur- 
rence, or complication. Though less dangerous than 
diarrhea, it is a troublesome and grave symptom. 

Swelling of the glands of the neck, when extreme, is 
mentioned by Dr. Clark and some other authors as a 
complication, although, in a majority of cases, these 
glands are more or less swollen and inflamed. The 
chief difficulty arising from extreme enlargement of the 
glands, is the obstruction it occasions to respiration 
and deglutition. 

" Coma" says Dr. Clark, " is an occasional termina- 
tion ;" but as it does not always terminate the disease, 
nor the life of the patient, it may more properly be 
regarded as an accident — a complication. It is, how- 
ever, always an occurrence of dangerous import. 



120 DlPTHEKIA. 



SEQUELE OF DIPTHERIA. 

Almost all of the eruptive fevers, and more especially 
measles, scarlatina, and small-pox, are followed by 
many and often severe after-symptoms or secondary 
diseases, either the consequences of the disease, or of 
the treatment, or of both. And in this respect dip- 
theria very much resembles them. Prominent among 
these sequelae, authors mention various forms of pa- 
ralysis, otalgia, amaurosis, ophthalmia, headache, etc. 

" After apparent recovery from the immediate 
effects of the disease," says Dr. Slade, " in many cases, 
there still seems to be lurking in the system the 
morbid poison, whose special affinity is for the nervous 
system." 

Such is the language of the author of the u Fiske 
Fund Prize Essay," on " Diptberia ; its Nature and 
Treatment." And although the words are all in strict 
accordance with what is called the Medical Science 
of the nineteenth century, yet, judged by truly sci- 
entific principles, they are utterly nonsensical. A 
u morbid poison" implies the existence of a normal 
poison. But Nature teaches, and all the data of science, 
when correctly interpreted, affirm, that no poison is 
wholesome or normal, and hence no poison can need 
the qualification, morbid. Poison is poison, and that 
is all there is of it. AYho would think of saying " black 
blackness," as though some kinds of blackness might 
be white, or of some shade between ? It is true that 
there are white hlaclxberries, and, in a certain stage of 
development, hlackbevries may be said to be green when 
they are red; but poisons do not undergo organic 
transformations, nor do they, under any circumstances 



Sequels. 121 

of health or disease, change their relations to the living 
system. 

But more absurd even than the notion of a " morbid 
poison," is the idea that it has a " special affinity for 
the nervous system." It seems to me, that if medical 
authors would look a little closer to the definitions of 
their technical words and phrases, they would not fill 
their books with such vague and meaningless, not to 
say false and ridiculous statements. 

The only relation which a poison, be it " morbid" or 
otherwise, and the nervous system can hold to each 
other, is that of repugnance or antagonism, and this is 
exactly the opposite of affinity. In other words, 
instead of the poison having a special affinity for the 
nervous system, the whole living organism has a con- 
stitutional antipathy to the poison. 

" The most frequent form of paralysis," says Dr. 
Slacle, " has been that of the soft palate. The symp- 
toms are, a nasal twang in the speech, incapacity for 
suction, and the regurgitation of fluids by the nostrils." 

M. Trosseau states that, in consequence of the para- 
lytic affection being more local than general — in other 
words, the palate and pharynx being more usually 
affected with paralysis than the system generally — he 
was for a long time under the impression that the loss 
of power was dependent upon the inflammation of the 
coats of the nerves supplying these parts, and an 
infiltration producing pressure on their motor muscles. 
A more extensive experience, however, of the general 
character of the paralysis which accompanies and 
follows diptheritic affections, caused him to change 
his views, and he now believes that loss of power and 
sensibility is the direct consequence of the peculiar 
diptheritic poison acting generally on the system, and 

6 



122 DlPTHERIA. 

strangely modifying the blood. M. Trosseau also 
states that, many children who have been subjected to 
the operation of tracheotomy fall victims to paralysis 
of the epiglottis and larynx. 

Dr. Faure has more fully described the debility and 
paralysis which are so frequently supposed to be the 
sequelae of diptheria, but which are, I fear much more 
frequently, the effects of the drugs which are admin- 
istered for the cure of diptheria : 

" Some time after an attack of diptheria, from 
which the patient has so completely recovered that no 
trace of false membrane is left behind, the skin grows 
more and more colorless without apparent cause, so 
that at length it assumes almost a livid pallor. Severe 
pains begin at the same time to be felt in the joints, 
the patient loses power over his limbs, and soon sinks 
into a state of indescribable weakness. At the same 
time, the disorders that appear in different functions 
show that the various organs which should minister to 
them are involved so far as they are dependent upon 
muscular power. In this respect, however, the phe- 
nomena are not constant, for sometimes it is one set of 
organs, and sometimes another which suffers most 
from this weakness. Very generally, in consequence 
of the want of muscular power, the patient becomes 
unable to sit upright, or does so with great difficulty, 
while the legs can not bear the weight of the body ; all 
the movements grow uncertain, tottering, hesitating, 
and apparently purposeless. Very remarkable disor- 
ders show themselves also within the throat, for the 
velum is completely paralyzed, and hangs down like a 
flaccid, lifeless curtain, which interferes with speech 
and deglutition. All the muscles of the jaw, neck, 
and chest are partially paralyzed, in consequence of 



Sequelae. 123 

which mastication is rendered difficult, and the food 
can be neither easily moved about in the month nor 
readily swallowed. Yision is impaired, and squinting 
is not unusual. The sensibility of the skin is much di- 
minished, in the limbs it is sometimes completely lost, 
though morbid sensations, such, for instance, as formi- 
cation, are sometimes experienced. (Edema of the 
various parts often occurs, and occasionally parts here 
and there lose their vitality and become gangrenous. 
No general reaction occurs ; fever is rare. The fea- 
tures grow duller and more and more expressionless, 
though a foolish smile sometimes crosses them, or now 
and then a ray of intelligence appears. Some patients 
have frequent fainting fits. As the condition goes on 
from bad to worse, the weakness becomes extreme, and 
death at length follows some fainting fit, or takes place 
when exhaustion has reached its uttermost ; life, as it 
were, quietly, almost imperceptibly, passing away." 

Dr. Greenhow remarks : " Under the most favorable 
circumstances, persons who have suffered from fully 
developed diptheria often remain feeble, ailing, and 
ansemic for many weeks ; and the throat sometimes 
continues to present traces of the disease long after- 
ward, or is very susceptible to the influence of cold or 
raw weather. Occasionally, many months elapse be- 
fore perfect recovery ; and I have known one instance 
in which the patient did not regain his strength for 
nearly a year. Besides the extreme anaemic which is 
so marked a result of diptheria, this disease is very apt 
to be followed by certain nervous affections of a pe- 
culiar kind. These consist of paralysis and anesthe- 
sia of particular muscles, tenderness and tingling of 
the skin, gastrodynia, impairment of vision, and deaf- 
ness. 



124 DlPTHERIA. 

" Few persons recover without impaired voice or 
power of deglutition, arising from paralysis of the 
muscles of the throat ; and sometimes, though rarely, 
there is complete aphonia, or absolute inability to 
swallow. The husky, nasal voice which follows dip- 
theria is very striking, and closely analogous in char- 
acter to that of persons suffering from syphilitic affec- 
tion of the throat. It is remarkable that this affection, 
in common with the other nervous sequelae not yet de- 
scribed, very often does not manifest itself until the 
patient is in other respects convalescent. The impaired 
power of deglutition consists sometimes of a difficulty 
in swallowing liquids, sometimes solids ; but the for- 
mer is the more common. Patients are sometimes 
able to eat a hearty meal without difficulty, but when 
they attempt to drink, a large portion of the liquid is 
regurgitated through the nostrils. 

" The difficulty in swallowing liquids^ and the nasal 
tone of the voice, are usually found in the same person ; 
and although the voice is sometimes slightly affected 
without impaired power of deglutition, the latter is 
very rare without the former. Difficulty in swallow- 
ing solids, when the power of swallowing liquids is 
comparatively perfect, occurs but seldom. 

u Paralysis of the muscles of the neck, producing 
inability to carry the head erect, is an occasional, but 
rare, sequel of the disease. Among a great many con- 
valescents from diptheria that I have seen, not one has 
suffered from this affection." 

The following case — interesting chiefly because of 
the time that elapsed between the affection of the 
throat and the development of the secondary disease 
— has been published by Dr. Gull, in the London Lan- 
cet : 



Sequelae. 125 

" A boy, eleven years of age, had an affection of the 
throat from which he convalesced, and was sent into 
the country for change of air. About five weeks from 
the time of his being taken ill, it was noticed that he 
did not carry the head erect — it drooped to one side or 
the other. There was an occasional difficulty in deglu- 
tition, loss of voice, and attacks of dyspnoea, threaten- 
ing asphyxia. In a day or two from the beginning of 
these symptoms, the breathing became entirely tho- 
racic. The diaphragm was unmoved in inspiration 
and depressed in expiration, indicating a loss of power 
in the phrenic nerves. Deglutition was next to impos- 
sible. The child could utter no sound. There were 
fearful attacks of strangulation when the head was 
moved in particular positions, and even when the 
breathing was at the best, there were blueness of the 
lips and tracheal rales. The intelligence remained un- 
affected. The legs could be moved only feebly ; the 
movement of the arms was not impaired ; the muscles 
of the neck were wasted and flaccid ; there was no 
swelling of the fauces; over the transverse processes 
of the cervical vertebrae, on the right side, there was 
tenderness, and the adjacent deep-seated absorbent 
glands were slightly enlarged ; no febrile excitement. 
Pulse feeble, 90. A paroxysm of suffocation suddenly 
terminated the life of the patient." 

A singular paralysis of the muscles of the neck, oc- 
curring after diptheria, is reported by Mr. Grundy, of 
ISTewick, in the case of his own son. The head rolled 
about by its own weight backward, forward, and side 
wise, exciting fear of dislocation ; and when it settled, 
the child was apparently unable to move it, and looked 
about him with a curiously slow turning of the eye- 
ball. 



126 DlPTHERIA. 

" Paraplegia," says Dr. Greenhow, " is by no 
means an uncommon sequel of diptheria, and, though 
more rarely, paralysis of the arms. Sometimes the 
paralytic affection is of a hemiplegic character. The 
following case, which I had the opportunity of seeing 
with Dr. Morris, of Spalding, illustrates several of the 
points just mentioned, though the paralysis was less 
complete than in some other cases which I have seen : 
E. A., twenty- eight years of age, resides in a small 
but clean and wholesome house at Pinchbeck. His 
case was the worst that Dr. Morris had ever seen to re- 
cover. On Friday, January 28th, 1859, he felt a 
' nasty taste' in the mouth. On the following day he 
complained of sore throat, and on examination by Dr. 
Morris it was found to be congested and inflamed. 
On the 30th, the tonsils, soft palate, and posterior fau- 
ces were covered with false membrane, and the case 
subsequently became one of malignant diptheria. 
March 20 : patient very pallid and anaemic ; voice 
thick, snuffling, and nasal ; there is a white filmy patch 
on either side of the arch of the palate, that on the 
right side being the largest; the uvula has nearly 
sloughed away, and he says that at the time of its oc- 
currence the stench was so bad that he could scarcely 
bear it. On the right of the posterior fauces is a patch 
of opaque white false membrane, the size of a split 
pea ; the rest of the posterior fauces is covered with a 
semi-transparent secretion. Skin sweaty ; pulse 72, 
feeble. Sight a little dim ; complains of numbness in 
the belly, and in the legs, arms, and hands, but espe- 
cially in the left arm and leg. Is unable to dress him- 
self, from weakness of the arms ; has lately felt prick- 
ing as of pins and needles in the fingers ; is rather 
giddy when out of doors, and still has slight difficulty 



Sequelje. 127 

in swallowing. Three weeks since, his face was puffed 
in the morning, and there was slight edema of the 
feet and legs, particularly at night ; urine pale colored, 
clear, and free from albumen." 

It is to be regretted that, in the reports of these 
cases, no allusion whatever is made, except in rare 
cases, to the treatment. Says Dr. Bigelow, of Boston, 
in a late work (" Nature in Disease") : " The effect of 
remedies is so mixed up with the phenomena of dis- 
ease, that the mind has difficulty in separating them." 

I apprehend that the truth of this remark is quite as 
applicable to diptheria and its sequelse, as to all other 
forms of disease. The ordinary drug-medication of 
diptheria is enough in many cases to paralyze not only 
the muscles of the neck, but those of the whole sys- 
tem, as is partially illustrated in the following case 
related by Greenhow, in which we have a hint of some 
of the remedial measures employed : " A woman, hav- 
ing been recently confined, contracted diptheria from 
a patient in a neighboring bed. Alum in suffiations 
and applications of hydrochloric acid were resorted to, 
with the effect of removing all diptheritic exudation. 
On the tenth day she spoke with a nasal voice, and 
deglutition was very difficult, and accompanied with 
nasal regurgitation. A notable proportion of albumen 
was also found in the urine. The paralytic affection 
of the pharynx kept increasing, so that by the twenty- 
fifth or thirtieth day the woman could no longer swal- 
low, and was like to have died while trying to take 
some solids. About the fortieth day some improve- 
ment in this respect took place, but some numbness of 
the hands and feet was observed, as well as defective 
pronunciation from imperfect movement of the tongue. 
By the fiftieth day, progression had become uncertain. 



128 DlPTHERIA. 

and general nervous symptoms, chiefly consisting in 
delirium and convulsions, set in. The worst apprehen- 
sions were now entertained ; but musk having been 
administered, some improvement took place. So con- 
siderable, however, was the paralysis, that the patient 
could not raise herself without the assistance of two 
nurses. The bladder was also affected during two or 
three days, but not the rectum. With this paralytic 
condition anaesthesia coexisted, the patient remaining 
absolutely insensible to pricking with needles. On the 
hundred and fiftieth day the symptoms were so much 
ameliorated under the use of the syrup of the sulphate 
of strychnia, that the patient could get in and out of 
bed easily, could knit a little, and was able to distin- 
guish between wool and cotton by the touch. No dis- 
turbance of visual power took place, although during 
six weeks enormous quantities of albumen were found 
in the urine." 

The medication in the above case, though far from 
being as potent as is frequently prescribed, is amply 
sufficient, in my judgment, to account for all the com- 
plications and sequelae which afflicted the unfortunate 
woman, and for the protracted convalescence. All of 
the caustic and burning, pungent, local applications, 
including nitrate of silver, chlorate of potassa, alcohol, 
etc., are of paralyzing tendency, and any variety or 
quantity, if I may be allowed the expression, of " gen- 
eral nervous symptoms," may be justly attributed to 
their employment ; and when the effects of these rem- 
edies become ■" mixed up" with the phenomena of dis- 
ease, I know of no way in which the physician can 
separate them. 

Because the patient, after lingering one hundred and 
forty-nine days, in virtue of an enduring constitution, 



Sequelae. 129 

improved while taking the deadly dogbane, or because 
her symptoms became ameliorated while " under the 
use" of this drug, it by no means follows that the 
strychnine contributed to the amelioration of the symp- 
toms. On the contrary, any one who can reason from 
the physiological instead of the pathological stand-point 
— who can interpret the effects of remedies and the 
phenomena of disease by the unerring standard of the 
laws of Nature as manifested in and through the vital 
organism, instead of by the false and absurd dogmas 
of medical schools, as taught in their books on materia 
medica — will know absolutely that all such patients, 
when they improve or recover, do so in spite of the 
medicine. No person whose brain is not prepossessed 
and prejudiced by the false theories of the day which 
pass current in the world as medical science, can read 
the " modus operandi" of strychnine, as stated in any 
of the standard works on materia medica, and not 
come to the conclusion that its effects are in every case, 
and stage, and condition of diptheria, as well as in all 
of its complications, incidents, accidents, accompani- 
ments, concomitants, or sequelse (and the same is 
equally true of all other diseases), to prolong the pa- 
tient's sufferings, lessen his chance of final recovery, 
and render recovery less complete. 

" Impaired vision" says Dr. Greenhow, " is another 
common sequel of diptheria, which, like those already 
described, only comes on subsequently to recovery 
from the primary local disorder. The patient is usu- 
ally able to see distant objects with sufficient distinct- 
ness, but is unable to see things close at hand. In- 
deed, several of the most striking cases that have come 
under my notice were those of children who appeared to 
be quite well until, on returning to their studies, it was 

6* 



130 DlPTHERIA. 

found that they could not see to read. The defective 
vision comes on gradually ; first of all, the patient is 
unable to read small print, and can only read large 
print when held at a distance from the eye, a power 
which is also lost at a later perio'd. The restoration of 
sight is equally gradual." 

As I have never noticed any serious difficulty of 
vision as a sequel of diptheria, in cases where the pa- 
tient has been treated hygienically, and as quinine and 
other similar drugs are well known, when given in 
large doses, to affect the vision very seriously, I am ap- 
prehensive that this " sequel" of impaired vision has 
some definite relation to the medication. Many prac- 
titioners recommend the free use of quinine and other 
" supporting" agents throughout the whole course of 
the disease. Indeed, the plan of treating typhoid and 
other low fevers with brandy and quinine, from the 
commencement of the disease to the end of the con- 
valescence, on the senseless vagary of " keeping the 
patient up" while the disease runs its course, or on 
the equally chimerical fantasy of " carrying the patient 
through the disease," has recently been revived by 
Dr. Todd, of England, and some other practitioners, 
so that we may soon look for impaired vision — and 
also for deafness, which is a very common effect of 
quinine — among the very common sequelae of an ex- 
tensive range of febrile maladies. 

As an illustration of some of the nervous sequelae, 
the case of Dr. Moyce, of Rotherfield, Eng., is related : 
" On Nov. 8, 1858, he felt a sensation of pricking, 
which soon became burning, in the right tonsil. In 
the night there was much pain, with a sense of swell- 
ing. The next morning there was on the right tonsil 
a patch of exudation about the size of a farthing, 



Sequelae. 131 

which gradually extended forward almost to the teeth ; 
the left side was very slightly affected. There was 
much external swelling. After four or five days the 
exudation began to clear away, and then pain and 
difficulty in swallowing, amounting to agony, super- 
vened. In the course of three or four weeks he got 
about, and attended to his practice for a fortnight. 
During the latter half of December the tone of his 
voice became altered, and he began to have regurgita- 
tion of solid food, which would accumulate in the pos- 
terior nares until it caused spasmodic cough. He was 
able to swallow fluids, if taken very slowly. He now 
lost the use of his tongue, could not move it in eating, 
and his speech became unintelligible ; he also began 
to see double, and indistinctly, but could see with spec- 
tacles. Next followed tingling and tenderness of the 
palmar surface of the hands and fingers, accompanied 
with a peculiar hardness and roughness of the integu- 
ments. Presently the soles of the feet and toes were 
similarly affected, and then there was loss of power in 
the limbs, especially the legs. The arms were so weak 
that he was unable to feed himself. The symptoms re- 
mained unabated for eight or nine weeks, and then 
gradually diminished in the same order in which they 
had begun. Even now, after a lapse of two years and 
a half, he is not strong, and can neither walk nor swal- 
low so well as before his illness." 

It is deeply to be regretted that in so extraordinary 
a case affecting a medical man, not a word nor a hint 
should be given in relation to the treatment. If the 
Doctor dosed himself with calomel, quinine, stimu- 
lants, and tonics, alteratives and antiseptics, continu- 
ally, the " nervous sequelae" and the prolonged conva- 
lescence may be easily accounted for. 



132 DlPTHERIA. 

The following case, related by Dr. Gull, is suggestive 
of mereurialization, though not a word is said as to 
the treatment : 

" A boy, of rather delicate temperament, when re- 
covering from diptlieria, was suddenly seized with in- 
tense neuralgia in the left leg, which passed off after a 
day. It appeared to be connected w T ith the femoral vein, 
which was rather hard and very painful to the touch. 
After two days he became very restless, and, in a few 
hours, completely hemiplegia on the right side, includ- 
ing the face, and speechless. The action of the heart 
was most tumultuous, and the sounds muffled. The 
child rallied under the free use of wine and ammonia ; 
but the hemiplegia remained for many months, after 
which there was slow improvement." 

This " rallying" under the use of stimulants is one 
of the great delusions of the medical profession, and 
of the non-professional people. The effect or disturb- 
ance which is called " rallying," or " reaction," is the 
resistance of the living system to the poisons. It is the 
drug fever ; nor is it any the less injurious to the pa- 
tient because it is termed stimulation, and is caused by 
a drug which is termed medicine, than it is when it is 
called disease or fever, and is caused by a drug which 
is called a " morbid poison." 

Says Dr. Greenhow : " The majority of cases which 
are protracted until the development of the nervous 
sequelae, recover, but death occasionally takes place 
even at a remote period. Dr. Moyce mentions the 
death of a boy, aged eleven or twelve years, from ex- 
haustion during the paralytic stage, two months after 
he had been quite free from throat affection." 

In view of the ordinary treatment of diptheria, I 
think the above remarks should be understood as 



Sequelae. 133 

meaning, if the patient can survive both the disease 
and the remedies, he may recover sooner or later, al- 
though he may long suffer from the chronic disease 
induced by the medication. 

And still more to the point says the same author : 
" The nervous sequelae of diptheria are not always in 
proportion to the severity of the previous illness, and 
do not occur exclusively after the severest cases, but 
sometimes follow comparatively mild attacks. Their 
duration is uncertain, varying from two to three or 
four months, but the slighter affections may perhaps 
sometimes pass off in a shorter period than two 
months, and, in all probability, severe cases are occa- 
sionally prolonged beyond the fourth month." 

If the sequelae were legitimately the consequences 
of the diptheria, or of the causes of diptheria, it would 
logically and necessarily follow that the more severe 
the disease the greater the liability to sequelae, and the 
more severe the sequelae. But if the sequelae are 
chiefly attributable to the remedies employed for the 
cure of the diptheria, then we may properly expect 
just what our authors inform us is the fact, that mild 
cases of the disease may be attended with dangerous 
complications, or followed by severe sequelae, and vice 
versa. 

bronchitis and Pneumonia are named by some 
authors as complications, and by other authors as se- 
quelae of diptheria. But I think the bronchial af- 
fection is merely the extension of the diptheritic exu- 
dation to the bronchial tubes ; and that the pneumonia 
is the same with a more considerable degree of con- 
gestion in the lungs— a condition which may occur in 
the dying struggle. And these views are corroborated 
by all the circumstances of the cases adduced to 



134 DlPTHERTA. 

prove the existence of these affections. Mr. Thompson 
reports the following case, in the British Medical Jour- 
nal for June 5, 1858 : " A gentleman, aged forty-six, 
died from this condition of the lungs. His throat was 
first affected. After a few days the breathing became 
impeded, with all the ordinary symptoms of capillary 
bronchitis in the first stage, the throat continuing to 
improve. He gradually sank, constantly expectorating 
casts of the small tubes, precisely similar to the de- 
posits in the trachea." 

Drs. Greenhow, JBristowe, and others, state that 
they have only found the occurrence of pneumonia as 
a complication of diptheria has only come under their 
observation in post-mortem examinations. Mr. Rush, 
of Southampton, mentions two cases in which fatal 
pneumonia supervened after the exudation had disap- 
peared from the throat, and the patients were supposed 
to be doing well. 

The occurrence of fatal secondary diseases, long 
after convalescence in relation to the primary disease 
has been established, is always, to my mind, suggestive 
of drug-disease. And does not Professor Paine, in his 
" great work" (" Institutes of Medicine"), declare, as the 
basis and rationale of the whole drug system of med- 
ical practice, " we do but cure one disease by produc- 
ing another." 

MORBID ANATOMY OF DIPTHERIA. 

Post-mortem examinations can never reveal the es- 
sential nature nor the causes of any disease ; they can 
only exhibit the effects of disease — the morbid condi- 
tions which occur in its progress, and the structural 
derangements which take place after death. But these 



Morbid Anatomy. 135 

effects and derangements may be the results of the dis- 
ease itself, or of the medication, or of both. And if it 
is very difficult to discriminate between the phenome- 
na of disease and the effects of remedies in the living 
subject, it is still more difficult to determine, in the ca- 
daver, what appearances are due to the original dis- 
ease, or to its causes, or to the medicines, which are 
themselves morbific agents, and must of necessity in- 
duce disease. Hundreds of post-mortem examinations 
have been made after deaths of pneumonia — inflamma- 
tion of the lungs ; and when mercurial and antimo- 
nial remedies had been prescribed, there have been 
found as complications and sequelae, morbid conditions 
of the stomach and bowels to which the terms gastritis 
and enteritis are applicable. Whence this inflamma- 
tion of the stomach and bowels ? Dr. Ames, of Mont- 
gomery, Alabama, in an article published in the New 
Orleans Medical and Surgical Journal, a few years 
ago, states that these complications are found only in 
cases which have been treated with bleeding, calomel, 
tartar emetic, and other powerful drugs — never in 
cases treated with what are called simple remedies or 
milcl medicines. 

What do these facts prove ? What can they prove, 
except the admitted fact that all drug-medicines are 
poisons, that all poisons induce diseases, and that when 
poisons are administered as remedies to cure diseases, 
we must of necessity find the effects of remedies and 
the phenomena of disease so " mixed up" — to quote 
again the language of Dr. Bigelow — as to render it 
exceedingly difficult to distinguish the one from the 
other. 

In estimating the value of pathological anatomy, we 
must ever keep in mind that the dead structures can 



136 DiPTHERIA. 

only disclose the effects of morbific agents and pro- 
cesses ; they can never explain the remedial actions — 
the vital straggle — which constitutes the very essence 
of disease. My work would be incomplete without a 
chapter on this subject; and as Dr. Greenhow has pre- 
sented in his late work all of the facts pertaining to 
the morbid anatomy of diptheria which are known to 
the profession, or which can be of use in determining 
either the nature, the causes, or the proper treatment 
of the disease, with illustrative cases, I copy his en- 
tire article, premising that a careful examination of 
all evidences can hardly fail to convince the candid 
reader, especially if he is familiar with the effects of 
medicines as explained in the works on materia medica 
and therapeutics, that many of the morbid appearances 
described are quite as likely to be the effects of drug- 
poisons as of diptheria or its causes. 

" Diptheria is essentially an inflammation of the 
fauces, which sometimes only causes disordered secre- 
tion from the mucous membrane; at others, produces 
ulceration, and even gangrene ; but, more frequently, 
an exudation which, coagulating on the surface, forms 
the false membrane from which the disease obtains its 
name. The exudation varies in consistency from a 
pultaceous or almost liquid exudation to a firm, con- 
sistent, and more or less elastic membrane. In the 
latter case, its outer surface is often uneven, usually 
less dense than the deeper portion, and sometimes floc- 
culent or fissured. It varies from a quarter of a line 
to a line or more, and, in one instance I have seen, was 
nearly two lines in thickness. The elastic form of false 
membrane is not unlike the exudation poured out from 
an inflamed serous membrane. Sometimes the exuda- 
tion is not membranous, but dry and granular. 



Morbid Anatomy. 137 

"Low forms of ciyptogamic plants are occasionally 
found on the exudation, a circumstance which gave 
rise to the belief that the disease is of parasitic origin. 
This opinion is disproved by the facts that, on the one 
hand, the supposed parasite is not invariably present 
in diptheria ; and, on the other, that it is frequently 
found on unhealthy mucous surfaces which are not of 
a diptheritic nature. Examined under the microscope, 
the exudation is found to consist of coagulated fibrine 
and epithelium, the latter being usually more abundant 
in the outer portion, or layer of membrane ; while the 
deeper portion is more purely fibrinous. But in this 
respect there are numerous variations. Exudation cells 
are often intermixed with the fibrillated texture. The 
exudation is sometimes already undergoing decomposi- 
tion, or other change, before it leaves the throat, and 
is at others more or less stained with blood. At first 
only opaque, the exudation soon becomes white or ash- 
colored ; if thick and adherent, brownish or buff- 
colored ; and if stained by slight hemorrhage, black- 
ish. The exudation is sometimes very loosely, at others 
very firmly, adherent to the subjacent surface ; and occa- 
sionally, especially when of the friable, granular variety, 
is merely superimposed upon the natural surface. 

u The mucous membrane underneath the exudation, 
or from which the exudation has recently exfoliated, is 
often intact, and generally much congested and swollen ; 
sometimes it is white, opaque, or unnaturally pale ; at 
others it looks raw, the epithelium having been shed 
with the false membrane. It often presents an exco- 
riated and roughened appearance ; is sometimes ulce- 
rated, and, more rarely, gangrenous. When false mem- 
brane, still adherent to the mucous surface, is lifted up, 
it is often seen to be attached to the subjacent surface 



138 DlPTHERIA. 

by numerous small thready adhesions, as though pro- 
cesses of exudation passed into the mucous follicles ; 
and, on removing it, the mucous membrane is more or 
less abundantly dotted with bloody points. 

"The submucous tissue is often edematous, infil- 
trated with blood, and sometimes the seat of interstitial 
exudation. The tonsils are usually swollen, and, on 
being cut into, are often infiltrated with blood, so as to 
impart to them an ecchymosed appearance ; sometimes 
their tissue is softened ; and in two instances I have 
found the center of a tonsil in a state bordering on 
gangrene. There is generally more or less of inflam- 
matory effusion into the structure of the tonsils ; and 
in one instance, on the tonsil being laid open, there 
was an oozing from it of a creamy fluid resembling 
pus. In some instances, the esophagus and the mus- 
cular and other tissues around the fauces are congested 
or infiltrated with blood ; the parotid and submaxillary 
regions are much swollen, and the integuments studded 
with livid purpurous spots. In a case mentioned to 
me by Mr. Jauncy, of Birmingham, an abscess was 
found between the pharynx and vertebrae. The case 
was that of a child, aged six years, which died after 
an illness of nine or ten days, croupy symptoms having 
set in three days previous to death : 

" 'The lungs were emphysematous in front, collapsed 
in patches posteriorly. A portion of false membrane 
was found at the bifurcation of the trachea, which was 
elsewhere free from exudation, but reddened. The 
larynx, epiglottis, pharynx, tonsils, and uvula were 
covered with lymph. An abscess about the size of a 
walnut was found between the pharynx and vertebrae. 
Liver, kidneys, and spleen healthy. The kidneys were 
examined microscopically.' 



Moebid Anatomy. 139 

"When the disease extends to the larynx and tra- 
chea, the false membrane generally becomes thinner 
and less consistent as it descends in the tube, until it 
disappears gradually in the form either of a very thin 
pellicle, or of a creamy fluid. The mucous membrane 
of the affected portion of the larynx and trachea is 
generally more or less congested, and often thickened, 
so as to diminish the caliber of the passage, even after 
the false membrane has been removed, or has come 
away. The subjacent membrane is here, for the most 
part, intact ; but sometimes, being denuded of its epi- 
thelium, exhibits, on the removal of the exudation, a 
red excoriated appearance, somewhat like the raw sur- 
face produced by a blister. It also, under the same 
circumstances, presents small bloody points similar to 
those observed on the mucous membrane of the pha- 
rynx. The epiglottis, besides being covered above or 
below, or on both sides, with exudation, is likewise 
often swollen so as to contract the entrance to the 
windpipe. The bronchial tubes are sometimes lined 
with false membrane down to the third or fourth bifur- 
cations, and even lower ; and the lungs, sometimes 
partly emphysematous, are also liable to be affected 
with pneumonia, which is most commonly of the lobu- 
lar form. In the latter case, the little bits of spleni- 
fied lung are sometimes surrounded by crepitating and 
comparatively healthy lung, sometimes by portions of 
emphysematous lung. 

The kidneys have sometimes been found quite healthy 
after death from diptheria ; in other cases they have 
been congested, and, on being sliced, have exhibited 
under the microscope transparent fibrinous casts of the 
tubes. The urine, in such cases, is generally albumin- 
ous, and also presents under the microscope fibrinous 



140 DiPTHERIA. 

casts of the tubes, which occasionally contain blood 
corpuscles, or granules of hematine, or a few altered 
epithelial cells. 

" In a case briefly referred to by Dr. Gull, in his 
communication to the medical officer of the Privy 
Council, the membranes of the brain and cord were in 
a state of suppurative inflammation, the subarachnoid 
space being full of soft, purulent lymph; and the same 
physician, although he gives no post-mortem facts in 
supj)ort of the opinion, suggests that the original seat 
of the disease being near the cervical portion of the 
spinal cord, the paralytic symptoms so common in a 
late stage of diptheria may arise from the disease hav- 
ing extended by continuity, from the fauces to the upper 
part of the cord. At present, this opinion can only 
be received as suggesting a careful examination of the 
cord in future post-mortem examinations ; for thus only 
can it be determined whether the paralytic affection 
has a constitutional origin, or arises from the supposed 
local disease. 

" In a case related by Dr. Bristowe, and exhibited 
by him at the Pathological Society, the muscular tissue 
of the heart was colored with extra vasated blood. 
And in a more recent case, treated by the same physi- 
cian in St. Thomas's Hospital, in which I had the 
opportunity of examining the organs after death, the 
heart was studded with petechial spots on its outer 
surface. 

" The following cases are adduced in illustration of 
some of the points mentioned in the preceding account 
of the morbid anatomy of diptheria. The first has 
been selected because it well shows the tendency of 
the disease to become engrafted, so to speak, on other 
disorders, especially the eruptive fevers ; the others, 



Morbid Anatomy. 141 

mainly on account of the detailed description of the 
microscopical appearances noted by such competent 
observers as Mr. Simon and Dr. Bristowe. 

" S. Beard, aged four years, was admitted a patient 
of the Western General Dispensary, under the care of 
my colleague, Dr. Sanderson, on June 29, 1859. She 
had been taken ill on the previous day with the pre- 
monitory symptoms of measles, and was visited by the 
house surgeon, Mr. Plaskitt. It was not until the 4th 
of July that she complained of her throat ; and she 
first came under the observation of Dr. Sanderson on 
the 6th of that month. The skin was then of a not 
unnatural warmth ; the countenance was pale, and its 
expression rather distressed. The child was somewhat 
drowsy, and difficult to rouse ; there was a slight dis- 
charge from the nostrils, which were lined with coagu- 
lated blood arising from an epistaxis on the previous 
day. Respiration natural in frequency ; pulse 120 ; 
the mucous membrane covering the tonsils was of a 
deep-red color, but less bright than is usual in ordinary 
tonsillitis. The anterior surface of the uvula was bare, 
but the posterior surface and sides were covered with 
a soft concretion, capable of being detached, and evi- 
dently of slight consistence. All the parts were 
smeared with a tenacious mucus, which was constantly 
being discharged from the mouth ; and flakes of con- 
cretion, which had been excreted during the preceding 
night, were exhibited by the mother. There was very 
little external swelling or tenderness about the neck, 
and the breathing was not at all croupy, although said 
to have been so. Urine intensely albuminous. 

u July 7. — A tubular cast, of soft consistence, distinct- 
ly marked by the laryngeal rings, was discharged dur- 
ing the night. 



142 DlPTHERIA. 

" July 8. — Much worse ; feet and hands warm ; belly 
hot. Pulse 160, feeble, and very difficult to count; 
respirations about 30. Prolonged, somewhat musical 
expiration sound, varying in tone from minute to min- 
ute ; inspiration sound, short, less noisy, and not musi- 
cal. Countenance pale, but not livid. Yoice resembled 
a shrill whisper heard through a long tube. The cough, 
which occurred occasionally, was very short, and pre- 
cisely similar in tone to the voice. A few small shreds 
of concretion were still attached to the uvula and vel- 
um ; but none elsewhere. There were excoriations at 
the corners of the mouth, not covered with concretion. 
Mucous surface of a deep-crimson hue. 

" Vespere. — Respiration increased in frequency to 40 
in the minute ; countenance more indicative of distress. 
She died at seven a.m., on the 9th. 

"Post-mortem Examination (made June 10, twenty- 
seven hours after death). — Slight mottling on the arms, 
probably the remains of the eruption of measles. The 
upper surface of the tongue was healthy as far back- 
ward as the base of the epiglottis, excepting that there 
was a small patch of exudation, not much larger than 
a grain of wheat, adherent to one of the large papillae. 
The subjacent surface was healthy ; both tonsils, espe- 
cially the right, were vascular, and presented a pitted, 
roughened appearance. The mucous membrane cover- 
ing the margin of the epiglottis, epiglottidean folds, 
and arytenoid cartilages, was white and opaque. The 
anterior portion and edges of the upper surface of the 
epiglottis were of a brownish- white color. The mu- 
cous membrane of a cavity behind the left tonsil and 
between.it and the posterior pillar of the fauces con- 
tained a creamy-looking exudation. The corresponding 
hollow on the right side was free from exudation. The 



Morbid Anatomy. 143 

substance of the tonsils, particularly of the right, was 
decidedly softened. On being incised, they exhibited 
patches of extravasation and of pigmentary discolora- 
tion ; but in other respects the section presented a 
natural aspect. The mucous membrane of the larynx 
and trachea was unnaturally white and opaque, as 
though covered with exudation ; but nothing could be 
stripped off it. This condition of the membrane be- 
came less and less obvious in a downward direction. 
Here and there were seen punctuated patches of red- 
ness, which sometimes followed the intervals between 
the rings of the trachea. Several loose fragments 
of exudation, some of which, although readily de- 
tached, were still adherent to the natural surface, were 
found in the upper part of the trachea. The subjacent 
mucous membrane was unbroken, and closely resem- 
bled the surrounding mucous surface. 

" The apex and upper portion of the left lung, as far 
as a line extending upward and backward from the 
notch, was emphysematous, and along the free mar- 
gin were emphysematous lobules, surrounded by por- 
tions of splenified lung. The lingua and margin of 
notch were completely splenified. The secondary di- 
vision of the bronchus leading to the apex of the left 
lung contained cylindrical casts, of about the consist- 
ence of boiled macaroni, at their proximate extremity, 
but diminishing in consistency until they disappeared 
in the third or fourth division of the bronchus, in the 
form of creamy-looking fluid. The division of the 
bronchus leading to the lower lobe contained no casts, 
excepting in one of the tertiary divisions leading to- 
ward its posterior aspect. It was not ascertained 
whether or not this portion of exudation was continu- 
ous with that in the bronchus leading to the apex. 



144 DlPTHERIA. 

The mucous membrane was for the most part remark- 
ably pale, but otherwise healthy. There was bronchi- 
tis in a few of the smaller tubes, as shown by the 
frothy secretion which they contained, and by slight 
vascularity. The parenchyma was firmly splenified 
throughout the lower lobe, with here and there scat- 
tered portions of emphysematous lung. 

" The two upper lobes of the right lung were em- 
physematous ; the lower lobe was also emphysema- 
tous at the upper portion, and partially so below. The 
bronchus leading to the apex contained here and there 
adherent, but also partly detached, patches or frag- 
ments of soft exudation, which ceased rather abruptly 
in the third bifurcation, and less decidedly terminated 
in creamy fluid than those on the left side. A consid- 
erable-sized tube leading toward the base of the upper 
lobe was choked with a cylindrical mass of semi-dif- 
fluent white and opaque secretion, which, under the 
microscope, exhibited cells without fibrinated matrix. 
The bronchial branches leading to the middle and 
lower lobes were free from exudation. The mucous 
membrane of the tubes in the upper lobe, like that on 
the left side, was perfectly white. That of the tubes 
leading to the middle and lower lobes on the right 
side markedly injected. 

" The following case, communicated to the Patholog- 
ical Society by Mr. Simon, is quoted from the Transac- 
tions of that Society for last year : 

" 4 A. H., set. thirteen, had been suffering from dip- 
theria for nineteen days before his death, and during 
the last eleven had been under treatment in St. 
Thomas's Hospital. On the eighth day of the disease 
a large mass of thick, dense, very fibrinous false mem- 
brane detached itself from the fauces, leaving the sur- 



Morbid Anatomy. 14-5 

face of the tonsils and soft palate raw (like that of skin 
from which the cuticle has been removed after blister- 
ing), but not ulcerated or sloughing. On part of 
this surface, a second thinner false membrane soon 
formed, and subsequently came away in shreds. There 
was irritating discharge from the nose, and during the 
last days of life some of the patient's drink escaped 
this way. Early in the disease there had been swell- 
ing below the jaw, but this had subsided many days 
before death. On the seventeenth day of the disease 
superficial ulceration began at the left tonsil, and on 
the eighteenth day had extended to the size of a shil- 
ling. On each of the last eleven days of life the urine 
was examined ; it always gave abundant precipitate 
with nitric acid, and latterly also with heat ; but 
in the earlier days it precipitated imperfectly with 
heat, and largely with acetic acid. Microscopically 
it showed fibrinous tubule-casts, containing traces 
of hemorrhage, but scarcely any renal epithelium. 
Throughout the progress of the disease the patient was 
pale, feeble, and disposed to be chilly, so that wine 
and much external warmth had from the first been 
necessary. The tongue was always moist. No erup- 
tion appeared upon the skin. There was no delirium 
or stupor, and neither cough nor any sign of laryngeal 
obstruction was observed. The respiration was natural 
till within a few hours of death, when it became short 
and hurried. 

" ' The following were the post-mortem appearances : 
With the exception of an occasional very delicate film, 
there was no false membrane about the fauces. In the 
situation of the left tonsil was a sloughy ulcer, some- 
what larger than a shilling. The posterior surface of 
the soft palate was congested., and there adhered to its 

7 ' 



146 DlPTHEEIA. 

somewhat swollen mucous membrane small patches of 
false membrane. In the recess of mucous membrane 
beside the epiglottis was an irregular depression, evi- 
dently the remains of an almost cicatrized ulcer. 
About an inch below the aperture of the glottis, the 
pharynx presented on its right side a small circular 
ulcer, about two lines in diameter, with somewhat 
raised margins, and on the left side another similar 
ulcer, about the size of a pin's head. In other respects 
the pharynx and esophagus were healthy. On wash- 
ing out the nares a strip of false membrane an inch in 
length was removed. The mucous membrane covering 
the septum showed patches of congestion, was thicken- 
ed, and had shreds of false membrane adherent to it. 

" ' Both lungs, except in their upper and anterior 
parts, were greatly congested with blood, and less 
crepitant than is natural, especially the lower lobes, 
whose posterior parts were in many places nearly or 
quite without air; and the most solidified portions 
broke down on firm pressure with the finger. At one 
section the exuding fluid was obviously purulent, and 
microscopical examination showed pus extensively in 
other parts of the hepatized structure. The bronchial 
mucous membrane was a little injected ; the tubes con- 
tained thin frothy fluid tinged with blood, or more 
tenacious reddened mucus. 

u ' The kidneys were large, and intensely congested. 
Sections of the cortex, microscopically examined, 
showed frequently the presence of large, transparent, 
colorless rods of apparently fibrinous material, soluble 
in acetic acid and liquor pottassse. These rods were 
sometimes floating free, sometimes partly or wholly 
held within urinary tubules, of which evidently they 
were casts. They were generally structureless, but (no 



Morbid Anatomy. 147 

doubt from the manner of their formation) had a dis- 
position to transverse fracture, and sometimes presented 
lines curving almost concentrically across them, or 
had this direction given to little clusters of granular 
matter, probably altered epithelium, which they occa- 
sionally contained. Apart from the presence of these 
casts, the tubular structure of the kidney was not very 
obviously diseased ; but, after prolonged and careful 
observation, it could confidently be said, that, at least 
in many parts, the cell-growth within it was redundant, 
so that the tubules were more opaque than natural, 
and had their interior canal encroached upon, or even 
quite occluded by an increased amount of epithelium. 
The Malpighian tufts within their capsules showed a 
little indistinctly. 

" ' The venous system was everywhere remarkably 
full of blood ; the liver was greatly congested ; the 
heart was healthy, with a firm coagulum in each of its 
four cavities.' 

" The next case, also taken from the Transactions of 
the Pathological Society r , is from a communication by 
Dr. Bristowe : 

" ' T. 1ST., set. ten, the son of a farm-laborer, was ad- 
mitted into St. Thomas's Hospital, under Mr. Solly's 
care, on the 12th of November, 1858, with contraction 
of the left wrist and elbow-joints, after a burn. On 
the 18th he was operated upon, and continued under 
mechanical treatment up to the commencement of the 
malady of which he died. He appeared perfectly well 
on the 20th of March, 1859, but on that day partook 
of some gin and other improper articles of diet. The 
following morning he had a slight attack of shivering, 
and seemed otherwise a little indisposed. On the 22d 
he complained of slight soreness of the throat. This 



148 DlPTHERIA. 

increased, and on the 24th the following notes were 
taken by the surgical register : 

" ' Throat much swollen externally, particularly on 
the right side. On looking into it, the right tonsil is 
seen filling up the fauces, and has upon it a pultaceous 
material. Pulse small and weak, 130 ; tongue furred ; 
skin cool.' 

" i On the 25th he was placed under my care. He 
has slept a little in the night, and is said to be now 
rather better than he has been. He is extremely fee- 
ble, however, not at all feverish, and perfectly rational. 
The skin is cool, and gives no indication of rash. Pulse 
small, weak, slightly irregular, and about 100. There 
is great tumefaction, hardness, and tenderness in the 
upper part of the throat, chiefly in the parotid and 
submaxillary regions, and more on the right side than 
on the left. The anterior half of the tongue is clean, 
and its papillae are healthy ; the posterior half is some- 
what furred. The right tonsil is much swollen, and 
covered by a thick wash-leather-like false membrane, 
which is prolonged from it on to the pillars of the 
fauces, over the right half of the soft palate, and to 
the edges of the posterior teeth. The nose bled this 
morning, and a little thin sanious fluid has continued 
to ooze from it. Has no pain anywhere except in the 
throat ; experiences pain and difficulty in swallowing, 
but can manage to take fluids. No cough or difficulty 
of breathing. Bowels opened yesterday. 

" ' March 26, two p.m. — Slept pretty well, but is 
much worse than he was. Skin cold, without trace of 
rash. Pulse quite imperceptible. Throat more swol- 
len, hard, painful on pressure, and studded on the right 
side with small congested points. Tongue dryish, but 
not much furred. The breath has a faint, gangrenous 



Morbid Anatomy. 149 

odor. There is no appreciable change in the condi- 
tion of the interior of the throat. Is quite sensible, 
but very restless. No cough, or embarrassment in 
breathing. He continued to sink, and died at half- 
past five, p.m., remaining sensible to the last. 5 

" The following were the post-mortem appearances : 
" ' The front and sides of the throat were thick and 
brawny; and the parotid and submaxillary regions 
were much swollen and hardened, especially on the 
right side, where also the integuments were studded 
with congested and livid spots. On cutting into the 
neck, its muscular and cellular tissues, from the integ- 
uments to the vertebrae, and from the ears and root of 
the tongue to the upper opening of the thorax, were 
found indurated and brawny, and so infiltrated with 
blood as to be everywhere almost black. There were 
no circumscribed fluid or clotted collections, but the 
blood was uniformly diffused throughout the tissues. 
There w T as no appearance of pus, and no visible indi- 
cation of inflammatory deposit. 

" 4 The soft palate and uvula, the tonsils and pillars 
of' the fauces, the esophagus and larynx, were all in- 
tensely and deeply congested, tumid, brawny, and 
covered in many places by toughish, adherent, ashy, 
false membrane, or by pultaceous puriform exudation. 
The soft palate was quite half an inch thick, infiltrated 
with blood, and studded with shreds of false mem- 
brane. The tonsils were swelled, but at the same time 
presented deep fissures and excavations, and were 
covered pretty completely by grayish-yellow false 
membrane. This was in parts thick, tough, and pretty 
firmly adherent ; but over the convexity of the tonsils 
became changed into a soft, pultaceous deposit, which 
seemed partly pus and partly superficial slough. On in- 



150 DlPTHERIA. 

cising the left tonsil it was found softened, deeply con- 
gested, partly infiltrated with blood, and studded with 
distinct pus-holding cavities ; and the surfaces of the 
fissures passing into it from the surface were soft, 
greenish, and slightly gangrenous. The right tonsil 
was generally in the same condition as the left, but 
presented several deep, distinctly gangrenous, fetid ex- 
cavations. The mucous surface at the base of the 
tongue and back of the pharynx was congested, and 
presented here and there shreds of adherent membrane. 
The mucous investment of the epiglottis, and indeed 
that of the whole larynx, were thickened, indurated, 
and deeply congested. The epiglottis was covered 
pretty extensively by a toughish adherent membrane, 
about half a line thick ; and a similar formation, in 
less abundance, was studded over the rest of the laryn- 
geal surface, and accumulated along the vocal cords. 
The trachea was congested, but otherwise healthy ; the 
esophagus also was healthy ; but the tissues immedi- 
ately surrounding them, like those of the rest of the 
neck, were infiltrated with blood. Several portions of 
the hard palate, and septum nasi, were removed, and 
their mucous covering was found congested, and lined 
by adherent false membrane. 

" l Pericardium healthy. Heart small, firmly con- 
tracted, and nearly empty, its auricle and right ven- 
tricle containing a little fibrinous clot only. The valves 
were healthy. The muscular tissue was generally pale ; 
but almost all the musculi papillares and carneae co- 
lumnse of the left ventricle, and the walls of the apical 
half in nearly their whole area, and to a depth varying 
irregularly from a quarter of an inch downward, were 
almost black from sanguineous infiltration. The same 
condition was observed in the right ventricle, but to a 



Morbid Anatomy. 151 

less extent, the papillary muscles and the parietes being 
studded irregularly and thickly with black, blood-in- 
filtrated patches of various sizes ; some so thick as to 
reach the external surface of the organ, and some dotted 
with white spots and patches, which looked at first sight 
like suppurating points. 

" ' Pleurae healthy. Lungs crepitant throughout, 
and not materially congested. They presented, how- 
ever, on their external surface, a few dark-red, almost 
black spots, about a quarter of an inch in diameter, 
which were found to correspond to small subjacent 
patches of solid, dark-colored, granular lung tissue. 
The bronchial tubes contained much secretion. 

" ' Peritonium healthy. Liver of usual size, gene- 
rally of normal color and consistence ; its surface and 
substance, however, were thinly studded with petechial 
spots. Spleen of usual size, pale, and of moderate 
consistence. There was a little efiPusion of blood in the 
sub-mucous and cellular tissues around the pancreas 
and supra-renal capsules ; and the latter organs pre- 
sented patches of extravasated blood in the interior, 
though apparently in other respects healthy. The 
cellular tissue of the mesentery was studded pretty 
thickly with small, and not very intensely-colored 
patches of congestion and extravasation. The stomach 
and intestines were healthy, but the ilium contained 
two lumbrici. The kidneys were of the usual size, pale, 
and apparently perfectly healthy. Aorta and vena 
cava healthy. 

" ' The false membrane about the fauces and neigh- 
boring parts was made up chiefly of a net-work of 
fibrillated lymph. The fibrillae were very irregular in 
outline and dimensions, but generally comparatively 
thick ; and they coalesced with one another in all di- 



152 DlPTHERIA. 

rections, so as to leave irregular spaces between them, 
which were small, and often not larger in diameter 
than the fibrillse themselves. When seen in thickness, 
the tissue above described presented a pebbly charac- 
ter, like that afforded by an accumulation of nuclei ; 
but the fallacious nature of this appearance was recog- 
nized on looking at the thin edge of a section ; or by 
adding acetic acid, which rendered the whole transpa- 
rent, at the same time expanding it, and bringing into 
view an exceedingly delicate and irregular net- work -of 
well and sharply-defined, occasionally bulging, fibers, 
which appeared to be, so to speak, the skeleton of the 
original net-work. In some places the false membrane 
consisted of an apparently uniform layer, composed of 
an extremely fine and indistinctly fibrillated tissue, 
studded with molecular matter, and presenting some- 
thing of a ground-glass character. Imperfect epithe- 
lium was entangled here and there in the substance of 
the membrane, but was most abundant on the super- 
ficial surface. 

" ' The pus-like fluid in the tonsils consisted of well- 
marked pus-cells characteristically affected by acetic 
acid. Some of the muscular tissue from the small 
muscles of the larynx and from those of the neck was 
examined, and found to be striated and healthy-look- 
ing; but the spaces between the fibers were loaded 
with blood-corpuscles. The cellular tissue in front of 
the epiglottis presented a net-work of fibrillated tissue 
like that constituting the false membrane itself ; but 
the meshes were larger and more distinct. The mus- 
cular tissue of the heart was found to be generally in 
an early stage of fatty degeneration, the transverse 
markings being nearly absent, and the fibers studded 
with minute molecules. But in the portions infiltrated 



Morbid Anatomy. 153 

with blood the degeneration was more advanced than 
elsewhere, the striae were wholly deficient, the fibers 
crowded, and in some cases opaque, with beads of oil, 
many of which were of considerable size. The white 
pus-like spots in the right ventricle consisted simply 
of muscular fibers extremely degenerated. 

" 'The kidneys, though looking healthy to the naked 
eye, were really much diseased. The Malphigian 
bodies were generally healthy, but a few presented 
accumulations of oily granules between the capsule, 
and contained tufts of vessels. The epithelium of the 
tubes was generally opaque and granular. In many 
instances the peripheral surface of the cylinder of cells 
presented numerous oily globules ; and not infre- 
quently the tubes appeared filled with separated and 
irregularly clustered epithelial cells, loaded with oil so 
as to be almost opaque. In a few cases, tubes were 
filled with recently extravasated blood ; and occasion- 
ally transparent casts were seen floating about the 
field of the microscope. The contents of the medul- 
lary tubules were more generally unhealthy even than 
those of the cortical ones. Many contained transparent 
fibrinous casts, and the majority presented oily, break- 
ing down, epithelial contents.' 

"I am indebted to Dr. Brisfowe for the following 
report of a case, which recently proved fatal in St. 
Thomas's Hospital. I had not the opportunity of see- 
ing the patient during life, but carefully examined the 
affected organs after death. 

" E. T., a girl, aged eleven years, suffering from 
club-foot, had been in St. Thomas's Hospital, under 
Mr. Solly's treatment, since May 22, 1860. On the 
evening of June 23d, she first complained of sore 
throat. This increased in severity during the next few 

7* 



154: DlPTHERIA. 

days ; pain and difficulty of swallowing came on, and 
on the afternoon of the 27th. she was placed under the 
care of Dr. Bristowe. There had been no marked 
febrile symptoms, no shivering, headache, or pains in 
the limbs. Neither in the ward nor among the child's 
friends had there been any cases of scarlet fever or 
diptheria ; but a little girl in an adjoining bed had 
been attacked, much about the same time, wdth a sore 
throat, which had disappeared in a day or two, and 
presented no unusual character. 

" 'June 27. — Is perfectly sensible and composed, hav- 
ing by no means the aspect of a person seriously ill. 
Has no headache, or pains about the limbs ; complains 
of a little thirst and loss of appetite, but no sickness, 
cough, or difficulty of breathing. Pulse 124. The 
pupils are natural. The skin is warm, but not dry, 
and without trace of rash. The external fauces on the 
right side are much swollen, very tense and tender, 
but not discolored. On looking into the throat, the 
right tonsil is seen to be so much enlarged as to appear 
almost to close the passage, and is covered in nearly 
its whole extent by a thick, grayish, false membrane. 
The uvula is pushed over to the left side, and almost 
concealed ; is somewhat thickened, and a little false 
membrane adheres to it. The left tonsil is hidden, and 
apparently not enlarged. The tongue is covered with 
a whity- brown fur, and its papillae are not prominent. 

Hirudines ij . faucibus externis. Catapl. lini postea. 
^ Chlorat. potass. gr. iv. 
Acid, hydrochl. fl)j. 
Aquas dist. f ss. 

4tis horis. 

" ' Milk diet. Strong beef tea. Two eggs. Wine, 
three glasses. 



Moebid Anatomy. 155 

" ' 28th. — Passed a comfortable night, and has taken 
all her wine and nourishment. The leeches have given 
her great relief. There is little appreciable change in 
either her general health or in the condition of the 
throat, except that the right side is less tense and ten- 
der than it was. The bowels are confined. 

Wine, 4 glasses. 

Pulv. rhsei c. hydrarg. 3j. statim. 

" ' 29th. — Was very restless during the night. The 
bow T els have been relieved, and she has been very sick. 
The skin is hot, and rather dry. No rash. Pulse 128. 
No pains anywhere excepting in the throat ; no cough 
or difficulty of breathing. Great pain and difficulty 
of swallowing. There is copious discharge from the 
nostrils. Tongue clean. The right side of the throat 
is in the same condition as yesterday ; but the left side 
also is now distinctly swelled and painful. The right 
tonsil is about as large as it was; but the membrane, 
which is thick and tough, is detached and curled up at 
the margins. The left tonsil is somewhat increased in 
size, and also presents a distinct false membrane. The 
uvula is seen with difficulty, but has a few patches on 
its surface. The lungs are resonant in front; but the 
respiratory sounds are masked by the noise produced 
in the throat. Urine albuminous. Sp. gr. 1,015. 
Wine, twelve glasses. 

" 'Toward the evening she grew considerably worse, 
and became very restless. The pulse rose to 152 ; a 
troublesome cough, at times a little croupy in charac- 
ter, came on ; the breathing became rapid (40 in the 
minute), and more noisy than it had been. She con- 
tinued perfectly sensible. 

" ' 3Qth, nine a.m. — Has been very restless all night, 
and has taken very little wine and nourishment in con- 



156 DlPTHERIA. 

sequence of inability and disinclination to swallow. Is 
now manifestly sinking ; is scarcely sensible, but can 
be roused ; breathing rapid, accompanied by loud rat- 
tle and frequent moans ; pulse imperceptible ; lips dry. 
Died at ten a.m. 

" ' Autopsy. — The body was in a fair condition. 
There were no traces of eruption or of desquamation. 
The right submaxillary region was much swelled and 
indurated ; the left also, and the intervening parts, were 
swelled, though in a less degree. 

" ' Chest. — Pericardium healthy. Heart of natural 
size, and for the most part healthy. Its external sur- 
face presented numerous petechial spots, and its cav- 
ities contained partly decolorized coagula. The pleurae 
were free from adhesions, and the upper lobe of the 
left lung was covered by a very thin film of recent 
granular lymph. The lungs were rather large, heavier 
than natural, and presented, when handled, the irreg- 
ularly solidified character distinctive of lobular pneu- 
monia. On section, the upper lobes of both lungs were 
found to furnish well-marked specimens of the con- 
dition just named. They were studded thickly with 
smallish solid masses, running to some extent into one 
another, and separated by an imperfect net-work of still 
crepitant, though congested, lung tissue. The solid 
masses varied in character ; in some instances were 
distinctly apoplectic, in others had the appearance of 
being due to simple carnification, and in others pre- 
sented various degrees of the brick-red tint and granu- 
lar condition belonging to red hepatization. The lower 
lobes were, in many respects, in the same condition as 
the upper ; but they presented a greater degree of sim- 
ple collapse, and, consequently, a less amount of crep- 
itant tissue ; the hepatized and apoplectic patches, too, 



Morbid Ajstatomy. 157 

were larger, and presented less of the lobular arrange- 
ment. The bronchial tubes were congested, and con- 
tained much frothy mucus. 

" ' The larynx, trachea, and adjacent parts were now 
removed and examined. The right tonsil was found to 
be very large, though scarcely so large as during life ; 
the left also was enlarged, but in a less degree than its 
fellow ; and the uvula and soft palate were somewhat 
thickened. The tonsils, soft palate, uvula, base of 
tongue, and posterior and lateral part of pharynx were 
covered, more or less completely, with tough, some- 
what elastic, whitish false membrane. On the base of 
the tongue and uvula it formed merely thin, scattered 
patches. But over the tonsils, pillars of the fauces, 
and rest of the pharynx, it formed layers of consider- 
able extent, and often more than half a line thick. The 
membrane had become generally more or less detached 
at the edges ; and that portion connected with the right 
tonsil had separated in nearly its whole extent, and 
hung as a loose, discolored mass, backward into the 
pharynx. On peeling the membrane off, it was found 
pretty firmly attached, and accurately molded to the 
inequalities of the subjacent mucous surface, which was 
congested, but not ulcerated. On section, the tonsils 
were seen to be deeply congested throughout, some- 
what softened, and studded thickly with small patches 
of yellowish (but not distinctly purulent) inflammatory 
deposit. The tissue of the soft palate and uvula was a 
little brawny. 

" ' The mucous membrane of the upper part of the 
larynx was congested and somewhat thickened ; and a 
thin false membrane covered the epiglottis, extended 
into* the aryteno-epiglottidean folds, and down to the 
superior vocal cords. False membrane also extended 



158 DlPTHERIA. 

into the sacculi laryngis, and was scattered in small 
patches over the mucous membrane for about an inch 
below. The greater part of the trachea was healthy. 

" ' Abdomen. — Peritoneum healthy. Liver healthy, 
but studded with a few pallid patches. Spleen, pan- 
creas, and super-renal capsules healthy. The mucous 
membrane of the stomach presented numerous petechial 
spots ; and Peyer's patches in the lower three feet of 
the ileum were remarkably distinct and prominent; in 
other respects the alimentary canal displayed nothing 
unusual. The kidneys did not look unhealthy ; but 
exhibited, in their cortical substance, alternate pallid 
and congested vertical streaks. Uterus and ovaries 
healthy. Larger blood-vessels natural. 

" ' Microscopic Examination. — The false membrane 
was identical in its intimate structure with those which 
I had formerly examined and described. The only 
unnatural character exhibited by the kidneys was, gen- 
eral great granularity of the epithelium, and conse- 
quent opacity of the undenuded tubules. It seemed, 
too, as though the individual cells were abnormally 
large. There was no trace of effused blood, and no 
casts. The Malpighian bodies were normal.' " 

DRUG TREATMENT OF DIPTHERIA. 

With all the data before us which careful observa- 
tion, extensive experience, keen analysis, history, mor- 
tuary statistics, and morbid anatomy can furnish, we 
now approach the really important and responsible 
part of our subject — the treatment of diptheria. All 
persons who will carefully read the history of all the 
wide-spread epidemics which have prevailed iii the 
world — the plague, the sweating sickness, the influenza, 



Drug Treatment. 159 

the scarlatina, the cholera, and the diptheria — can not 
fail to notice the wonderful harmony of medical au- 
thors in description and diagnosis, and the strange dis- 
cordance of medical practitioners in their manner of 
treatment. Physicians who agree precisely as to the 
seat, character, and causes of the disease, will recom- 
mend exactly opposite methods of treatment ; while 
others who disagree as to the type and diathesis of the 
malady, will agree in their plan of medication. This 
is not only true of diptheria and other pestilences, but 
of all diseases. And the explanation is, that the med- 
ical profession has a false theory of all diseases — of the 
nature of disease itself. 

The majority of physicians recognize the diptheritic 
exudation to be an inflammatory process. But what 
is inflammation? Here all is discord and confusion 
again. " It is increased action, and must be reduced," 
says one ; and in goes the lancet, or on go the leeches, 
or down go the emetics, the purgatives, the antiphlo- 
gistics, etc., and down and off goes the patient. 

" Inflammation is decreased action," says another, 
" and the patient must be sustained through it ;" and 
in and down go brandy and quinine, wine and cor- 
dials, beef-tea and egg-toddy. 

" The inflammation is specific" says a third, " and 
must be specifically counteracted;" and the mucous 
membrane is seared with lunar caustic, scorched with 
cayenne pepper, burned with alcohol, excoriated with 
chlorate of potassa, denuded with sulphate of zinc, 
corroded with hydrochloric acid, and constringed with 
preparations of iron. 

" The local inflammation is active" is the doctrine 
of another; and nitrate of potassa and antimonial wine 
are the remedies. 



160 DlPTHEElA. 

"The local inflammation is passive" exclaims an- 
other ; and aqua ammonia, and mustard poultices, and 
turpentine liniments, and alcoholic gargles are in requi- 
sition. 

" The exudation is a parasitic fungus" replies an- 
other ; and death to the animalcules is dealt out in the 
shape of calomel, nitrate of silver, anguintum, sul- 
phur, arsenic, iodine, iron, salt, alum, etc. 

" But the chief difficulty lies further back ; it is a 
Hood disease" says another ; and so he attacks the 
virus by sending an antidote, a counter-poison, a drug, 
a medicine into the blood, in the vain expectation that, 
in some mysterious manner the poison he sends into 
the system will neutralize or destroy a worse poison. 
Says Prof. Jos. M. Smith, M.D., of the New York Col- 
lege of Physicians and Surgeons : " All medicines 
which enter the circulation poison the bloody in the 
same manner as do the poisons that produce disease." 

" The disease is essentially a fever, and requires the 
alterative and evacuant plan, emetics, cathartics, di- 
aphoretics, etc.," is the teaching of another. 

" The fever is sthenic" exclaims another ; and digita- 
lis, antimony, niter, and acetate of ammonia are pre- 
scribed. 

" The fever is typhoid," replies another ; and the pa- 
tient is stimulated through the whole course of the dis- 
ease, and perhaps for months, if not years, after. 

All the books which have thus far been written on 
diptheria have recommended some form or modifica- 
tion of drug-medication ; and as I am writing one 
against drug-medication, and in favor of hygienic 
treatment, and as I wish to turn the public judgment 
as much as possible against drug treatment of every 
kind, I know not how I can better accomplish this ob- 



Drug Treatment. 161 

ject than by showing precisely what drug treatment is, 
according to the most approved authorities, and what 
the testimony of the different practitioners is, respect- 
ing the effects of the treatment as recommended by 
their professional brethren. If the reader does not 
see, in this expose, ample reason for discarding all 
drug-medication, and relying on hygienic agencies 
alone, " neither could he be convinced though one 
should rise from the dead." It will at least prepare 
him the better to appreciate the rationale of hygienic 
medication ; and I think this exposition will enable the 
candid mind to understand the why and wherefore of 
much of the mortality of diptheria, and of many of its 
complications and sequelae. 

Dr. Slade, who regards diptheria as a specific dis- 
ease, propagated by infection and contagion, and be- 
longing to the category of hlood diseases, remarks, in 
relation to the methods of treatment formerly in 
vogue : 

" Like all diseases which have prevailed epidemical- 
ly, and which have appalled by their severity and fatal- 
ity, or perplexed by their novelty, diptheria has been 
subjected to a great variety of treatment. It is only 
within the last four years that anything like a unan- 
imity has existed in the profession in regard to this 
important point. Not to go farther back than the 
period of Bretonneau's memoir on this subject, we 
shall find that an activity of treatment prevailed 
which would scarcely coincide with the ideas of the 
present day." 

What is "activity of treatment?" If this phrase 
has any meaning at all, it means killing. And we 
shall all be glad to know that such treatment does not 
coincide with the ideas of the present day. But I fear 



162 DiPTHERIA. 

it is the result of the practice of the present day, and 
even of that practice which Dr. Slade recommends. 
Dr. Slade continues : 

" Bleeding, both local and general, blisters, certain 
local applications to the pharynx, rapid mercurializa- 
tion, formed the treatment in all cases. Mercury, in 
fact, was considered as the sheet-anchor by a great 
majority of medical men. To quote the words of Dr. 
Samuel Bard : ' But, although I consider mercury as 
the basis of the cure, especially in the beginning of the 
disease, I do not by any means intend to condemn or 
omit the use of proper alexipharmics and antiseptics.' 
Although a few practitioners may still make use of 
this therapeutic agent, it is now generally agreed that 
such is the asthenic nature of the disease at the present 
day, that depletion is not borne well in any form, 
neither is the action of mercury defensible either in 
theory or practice." 

If depletion can not be borne in diptheria, it is be- 
cause the patient sinks under it ; and if the use of mer- 
cury is not defensible, it is because it damages or kills 
the patient. That such are the results of these "ther- 
apeutic" agents. Dr. Slade testifies, though in a very 
gingerly manner ; and it is a sad pity that the profes- 
sion can not see that this truth applies to all other feb- 
rile and inflammatory diseases — and even to venereal 
diseases, for which it is claimed to be the " specific 
remedy" — as well as to diptheria. Says Dr. Slade 
again : 

"As we are not yet acquainted with any specific 
capable of arresting the course of diptheria, our treat- 
ment must be directed simply to the conducting our 
patient in his progress through the disease." 

Think, reader, seriously, for one moment, of the idea 



Drug Treatment. 163 

of a patient being conducted through a disease ! More 
frequently still we hear of a disease "running its 
course" through the patient. Is it not about time that 
the profession settled the question, whether the patient 
passes through disease or disease passes through the 
patient? But such expressions, it will be claimed, 
are not literal but figurative. They are literal non- 
sense and figurative foolishness. They indicate, as 
well as language can, the " incoherent expressions of 
incoherent ideas," which constitute the chief burden of 
medical literature, so far as the nature of disease and 
the action of remedies are concerned. When medical 
writers learn the simple truth, that disease is not a thing 
which runs through living organisms, nor which can be 
run through by a person, they will cease to employ 
such senseless and unmeaning language. And when 
they understand that disease is vital action in relation 
to things abnormal, they will see a better way to treat 
it than by the administration of drug-medicines. 

Dr. Slade objects to blisters, because their irritation 
aggravates the engorgement and cellular infiltration, 
and also because the blistered surface is liable to put 
on a diptheritic or sloughy appearance ; and he con- 
demns bleeding, " except, perhaps, in very rare excep- 
tional cases." Emetics, he thinks, may be advisable 
" under certain circumstances," and when there is a 
tendency to croupal symptoms ; and then he recom- 
mends full doses of ipecac. He condemns " anything 
like purging," but approves simple enemas and mild 
laxatives. 

" There are occasional cases of diptheria so mild in 
character that local applications to the fauces may be 
sufficient; but as a general rule it may be conceded 
that the disease requires a tonic and sustaining treat- 



164 DiPTHERIA. 

ment ; particularly is this often the case at a late period 
of the disease." 

Can it be possible that the disease requires a tonic 
and sustaining treatment ? So says Darnel Dennison 
Slade, M.D., of Boston, Mass. ; and Dr. Slade received 
a premium of one hundred dollars awarded by the 
Trustees of the Fiske Fund, at their annual meeting 
held at Newport, E. I., July 11, 1860, said Trustees 
consisting of James H. Eldridge, M.D., of East Green- 
wich, Charles W. Parsons, M.D., of Providence, and 
Henry D. Turner, M.D., of Newport — all of which 
facts are attested by S. Aug. Arnold, M.D., of Provi- 
dence, the Secretary of the Fiske Fund — for the Essay 
which contains this somewhat startling announcement. 
And it may be pertinent also to remark, in this place, 
that this Prize Essay which contains this remarkable 
statement, was published in the American Journal of 
the Medical Sciences for January, 1861, from which it 
has been reprinted in book form for consultation and 
reference. 

"Were it not that we are dealing with a Prize Essay, 
indorsed by the Rhode Island Medical Society, we 
might be disposed to criticise the idea and dispute the 
propriety of sustaining the diptheria with tonic treat- 
ment. If anything requires tonic and sustaining 
treatment, it seems to me it is the patient, and not the 
disease. But as Dr. Slade says it is the disease which 
requires, and as the " authorities" are all on his side, I 
suppose we shall have to submit, which I do under the 
protest that I can not comprehend the matter at all. 
And the author has still further complicated the mat- 
ter, in representing that the disease requires the tonic 
and sustaining treatment particularly at a late period 
of the disorder ; in other words, diptheria should be 



Drug Treatment. 165 

sustained by tonics in a late period of diptlieria ! Why 
not let the disease run down and die if it will ? I can 
imagine no method for sustaining the disease except to 
add to its causes, and that would be feeding the dip- 
theria sure enough ! But I am of opinion that we had 
better feed the patient — add to his causes — and let the 
diptlieria go. 

But, after all, Dr. Slade has employed none but rec- 
ognized medical parlance. There is not an author of 
a text-book on The Practice of Medicine who does not 
frequently use language in the same sense, or the same 
nonsense, and who does not habitually confound causes 
of diseases, consequences of diseases, the actions of 
disease, the disease itself, and the patient. Nor will 
they, nor can they ever avoid this confusion worse con- 
founded until they get a new and a true theory of the 
nature of disease, and of its relation to the vital organ- 
ism. Says Dr. Slade : 

" Stimulants and nourishment should be commenced 
with early, and persisted in systematically. The 
amount, of course, must depend upon circumstances; 
but in order to insure efficiency, they should be varied, 
should be given in small doses at regular and frequent 
intervals, and if rejected by the stomach should be 
given in the form of enemata. So also with respect to 
children, when they are frightened and disturbed by 
painful attempts at swallowing, and absolutely refuse 
everything, we have the same resource: Injections of 
beef-tea, with brandy and quinine, may be employed, 
and thus life may be not unfrequently sustained, when 
otherwise it would inevitably have been extinguished." 

As it is " life" now, and not disease that is to be sus- 
tained, I go for the principle, but do not like Dr. 
Slade's manner of applying it. I must infer from his 



166 DlPTHERIA. 

medico-alimentary medley that he is still a little mud- 
dled as to what he ought to prescribe for. Beef-tea is 
poor nourishment for diptheria ; and brandy and qui- 
nine are wretched food for the patient. Beef, being 
food, may contribute to the life of the patient ; while 
brandy and quinine, being poisons, must inevitably 
add to the causes of disease. In almost every instance 
in which we have known a practitioner to get inextri- 
cably befogged between conflicting theories, or to be- 
come perplexingly embarrassed with " indications and 
contra-indications," or to be grievously harassed with 
doubt whether he ought to give one set of remedies or 
just the opposite, he has solved the difficulty by a 
compromise, adopting a little of each of the theories, 
and mixing up some of both kinds of remedies. And 
this seems to have been the case with Dr. Slade. 

" With regard to the particular form of tonics," says 
Dr. Slade, " there is a variety of opinion. There are 
some which, perhaps, promise a greater chance of suc- 
cess than others, among which we may mention qui- 
nine, tincture of chloride of iron, and chlorate of pot- 
ash. But as each of these has powerful advocates in its 
favor, we imagine that, provided the strength of the 
patient be sustained, it is of little importance by which 
of these tonics it is accomplished." 

" Provided ' V But there's the rub. If one poison 
will sustain the strength of the patient — and we ought 
to be thankful to know distinctly that it is the patient 
and not the disease, the "strength of the patient" that 
should be sustained — it is not, of course, of so very 
much importance what other poisons are administered 
or withheld, whether their advocates be powerful or 
weak. 

After indicating his preference for the tincture of 



Drvg Treatment. 167 

sesqui-chlo^ide of iron — as the best of the many inter- 
nal remedies which have been advised — with chlorate 
of potash, chloric ether, and hydrochloric acid in the 
form of mixture, sweetened with syrup, and given in 
full and frequent doses, Dr. Slade quotes approvingly 
from the Lancet the following remarkable passage : 

" A free use should be made of generous wine, beef- 
tea, coffee, eggs, in combination with brandy and wine, 
milk, and whatever other form of nutriment the in- 
genuity of the surgeon or the fancy of the patient can 
suggest." 

A more horrid jumble of dietetic druggery, or med- 
icated food, can scarcely be imagined; but if surgical 
ingenuity, constructive or destructive, or invalid fancy, 
normal or morbid, can suggest anything else, by all 
means let the patient have it ! Is this the medical 
science of the nineteenth century ? Is this the healing 
art of a.d. 1862 ? And is a prescription of diet and 
drugs, separately or in combination, a surgical process, 
to be devised by the " ingenuity of the surgeon ?" It 
is not even a chemical combination, but a mechanical 
admixture of pathological and alimentary ingredients, 
anti-pharmacologically compounded, and most unphys- 
iologically confounded. Were not our subject a grave 
one, we should be disposed to wield no weapon but 
that of ridicule against such superlative nonsense. 

But, seriously, we protest against stuffing the stomach 
with anything, much less with these incongruous abom- 
inations. The patient can not digest food of any kind 
during the acute stage of the local inflammation, nor 
until the violence of the fever has subsided ; and to 
burden the system with anything which it can not use, 
under the circumstances, is merely to nourish and sus- 
tain the disease by adding to its causes. When the 



168 DlPTHERIA. 

vital powers are wholly occupied in a life-and-death 
struggle, as it were, to expel impurities from the ma- 
chinery of life, or to deterge a virus from the blood, they 
can digest nothing ; and to gorge the digestive appa- 
ratus with a promiscuous medley of slops and stimu- 
lants, is to sustain the disease and exhaust the vitality. 

I dwell on this point with some emphasis ; for there 
is no greater delusion in the world than that which 
mistakes stimulation for nutrition. The ideas are 
exactly antagonistical ; and yet the whole medical pro- 
fession has for ages, with less than one exception in a 
thousand, prescribed stimulants to support the vital 
powers, when the digestive function was feeble or sus- 
pended, as though stimulation was the equivalent of or 
a substitute for nutrition. Instead of supporting vital- 
ity, stimulants, of all kinds, exhaust it; they occasion 
its preternatural expenditure, and all such use of vital- 
ity is abuse / it is waste, and nothing else; as is all 
abnormal action under all circumstances. Need any 
one wonder at the grave complications, the numerous 
sequelae, and the many and serious cases of paralyzed 
muscles and prolonged convalescence, in view of such 
methods of treating diptheria, or drugging the patient? 

"We have now done with the general and leading 
remedies which Dr. Siade recommends to be adminis- 
tered to patients suffering of diptheria, and we come 
next to the local and auxiliary measures ; and as the 
Prize Essay of Dr. Slade is confessedly " a full and ac- 
curate resume of what is known concerning a disease 
which is now attracting universal attention," and is a 
fair compendium of the views and practices of the 
American medical profession, I propose to examine it 
somewhat critically to the end. 

" We come now to speak of the auxiliary measures 



Drug Treatment. 169 

to be adopted in the treatment of this disease, and first, 
of the local applications to the fauces/ The propriety 
of these has been called in question by some writers, 
on the ground that the disease is a constitutional one, 
and, therefore, that they can be of no service. But we 
must answer to this, that there can be no more reason 
why the local remedies are not as applicable to this 
affection as in other constitutional diseases, for exam- 
ple, as in syphilis, scrofula, carbuncle, etc." 

Dr. Slade next indorses as " excellent" the following 
reasons given by Dr. Bristowe for discarding heroic 
applications to the fauces : 

" 1. That the throat affection is merely a local evi- 
dence of a constitutional disease, which is unlikely to 
be arrested in its progress by any treatment directed to 
the secondary manifestations only. 2. That the throat 
affection rarely kills, except by involving organs, such 
as the trachea and deeper tissues of the neck, which 
are beyond the reach of the possible influence of such, 
agents. 3. That if the theoretical correctness even of 
such treatment be admitted, the application of reme- 
dies to the surface of a thick false membrane, with the 
hope that they may affect the subjacent mucous tissue, 
is not only clumsy, but, as regards the object intended, 
practically useless ; and that the prior forcible removal 
of the membrane from the entire surface, in order to 
their efficient employment, is unjustifiable in the early 
stage, even if possible, and is likely only to be followed 
by increased inflammation, and production of false 
membrane." 

Nevertheless Dr. Slade is for a compromise. He 
says : " While we concur in the remarks of Dr. Bris- 
towe so far as regards the forcible removal of the mem- 
brane, particularly in the early stages, the experience 

8 



170 DiPTHERIA. 

of almost all medical men of the present day bears 
witness to the efficacy of the application of caustics or 
escharotics to the throat." 

We think very little of the experience of medical 
men, who, in adopting a false theory of the nature of 
disease, must necessarily interpret the effects of reme- 
dies by erroneous standards. Experience informs us 
what medical men have done, not what they should do. 
And we shall see, presently, that some practitioners of 
great experience declare that caustics only aggravate 
the disease and extend the local inflammation ; they 
give a reason, too, why escharotics should not be em- 
ployed in any stage of diptheria ; and I can not help 
having more respect for one sound reason, one true 
principle, one demonstrated theory, than for all the ex 
perience of all the medical men of all the world in all 
the ages, so far as that experience is judged by the 
false standard of the prevalent medical doctrines. Dr. 
Slade continues : 

" On the other hand, some writers maintain that the 
disease at the outset is a local one, which rapidly 
brings on a general intoxication. This would be a 
still stronger argument — if we granted this to be true 
— for these very local remedies, if applied in season, 
might prevent 'a further extension of the disease." 

Surely the profession is in a most unfortunate pre- 
dicament — unfortunate at least for the parient — with 
regard to the rules of practice by which they should 
be governed in the treatment of diptheria. In the 
first place, the authors do not agree whether the dis- 
ease is general or local ; nor, if constitutional, whether 
general or local remedies are to be put most promi- 
nently forward in its treatment. But the reasoning 
of Dr. Bristowe, that the trachea and deeper tis- 



Drug Treatment. 171 

sues of the neck " are beyond the region of the pos- 
sible influence of such agents," I hold to be entirely 
and mischievously fallacious. Any poisonous agent 
in contact with any part of the living system, influ- 
ences, to some extent, every organ and structure. 
Its presence invariably occasions some disturbance in 
the part or organ to which it is applied, and a less 
degree of disturbance in organs and structures more- 
remote ; just as the presence of a thief in the family 
circle, or of a serpent in a promiscuous crowd, would 
occasion a general commotion among all the persons 
present, and a greater consternation or resistance 
among those in contact with or nearest to the offend- 
ing thing. It is true, the effect or influence of a poison 
on a part distant from the point of contact, is not al- 
ways appreciable, nor is its local influence always ap- 
parent ; yet, if we understand the law of constitution 
and relation between dead and living matter, we know 
that, whether cognizable to our senses or not, some 
effect must result, just as we know that when we add 
a drop of water to the Croton Reservoir, the bulk of 
the whole mass of fluid is increased, although our eyes 
can see no difference. The constant dripping of the 
soft water will in time wear away the solid rock ; yet 
our eyes could recognize no change from day to day ; 
and so the constant use of stimulants, irritants, nerv- 
ines, narcotics, and, indeed, of any other drug or 
poison, gradually and imperceptibly exhausts the life- 
power, until the accumulated debility brings us to the 
recognition of the law of vitality, and the consequences 
of abnormal vital expenditure. 

It is quite common for medical men to say, when 
their remedies have not benefited the patient, that 
they have had no effect whatever. This is impossible. 



172 DlPTHEEIA. 

They do and must occasion vital action. Nothing can 
be inert or neutral in relation to the living organism. 
It is either useful or injurious ; and its administration 
as a medicine, as well as its accidental presence, must 
and does alwaj^s, and under any circumstance, exercise, 
so to speak, an influence. Of the individual agents 
employed as local applications, Dr. Slade testifies very 
dubiously and rather ambiguously : 

" There are a multitude of substances which have 
been employed as local applications to the fauces, 
all of which have their special advocates. During 
the last four years, the nitrate of silver, either solid or 
in solution, has been perhaps more extensively used 
than any other substance. This, when used early in 
the disease, seems in many cases to check the progress 
of the exudation ; yet it does not answer the purpose 
altogether, and further experience has somewhat di- 
minished confidence in it. Indeed, in some instances 
it is a question whether the free application of this 
caustic does not rather add to the evil." 

Nitrate of silver, we are told, has been more exten- 
sively employed than any other caustic, and experience 
diminishes confidence in it. What are we to do ? Dr. 
Slade has told us, a little way back, that " the experi- 
ence of almost all medical men of the present day 
bears witness to the efficacy of the application of caus- 
tics or escharotics to the throat." The testimony is in 
favor of some cauterizing agent, and against nitrate of 
silver. What, then, is the proper article ? Dr. Slade 
solves the difficulty in his usual half-and-half compro- 
mising manner : 

" Still, if carefully and properly used, nitrate of sil- 
ver in many cases is undoubtedly of benefit. If in 
solution, it is to be applied by means of a probang or 



Drug Treatment. 173 

brush, swabbing over the diseased surface quickly, at 
the same time thoroughly. The strength of the solu- 
tion should be from 30 to 60 grains, and perhaps 
higher, to the ounce of water, according to circum- 
stances. For children, a full-sized camel's hair brush 
is best. The child should be placed on the lap of an 
attendant, and the head firmly fixed. If he will not 
open the mouth, the nostrils should be closed for a few 
moments, and as he opens the mouth for breath, the 
jaw should be at once depressed, and then, the tongue 
being kept down by the finger, the fauces are brought 
well into view, and the solution thus thoroughly ap- 
plied. The utmost gentleness and patience should be 
exercised; at the same time, firmness, for upon the 
effectual accomplishment of this proceeding the suc- 
cess of the treatment will greatly depend. This should 
be repeated every three or four hours, so long as it is 
necessary." 

" According to circumstances," " and so long as it is 
necessary," are rather loose and indefinite rules for the 
application of so potent an agent, especially when we 
are given to understand that the profession is divided 
on the question whether it tends to cure the disease or 
to kill the patient ; and more especially when our au- 
thor is himself partly on both sides of the question, and 
partly between the rival opinions. Nevertheless, Dr. 
Slade, with commendable candor, quotes a brief chap- 
ter of the evils of cauterization, from the pen of F. A. 
Bulley, F. E. 0. S., and the Medical Times and Ga- 
zette for April, 1859: 

" I have mentioned that I thought that the indis- 
criminate mopping of the fauces, as it is called, with 
solutions of nitrate of silver, was frequently attended 
with injurious results in this disease, principally, I 



174 DlPTHERIA. 

believe, for this reason, that, owing to the struggles of 
the little patient, it is impossible to apply the caustic 
solution with that precision which the case absolutely re- 
quires. Thus, it is applied to parts which are entirely 
free from disease. I have been told of cases where 
the inside of the cheeks have been covered with it ; 
in coughing, a portion of it has been expelled upward 
through the nose, corroding the susceptible surface of 
its mucous membrane ; and again, other portions of it 
have seemed to pass downward into the pharynx and 
esophagus ; and I am not sure that, during the convul- 
sive struggling of the patient in resistance, some of it 
may not also enter the larynx, where it may possibly 
initiate those inflammatory changes in the mucous 
membrane of the air-passages, which are too frequent- 
ly the harbinger of death in this disease." 

To the adverse testimony of Dr. Bulley, Dr. Slade 
adds the following pro and con: 

" The nitrate of silver may also be employed in the 
solid form, but this we should not advise, particularly 
in the case of children. During the struggles of the 
little patient the crayon might become broken, an ac- 
cident which has happened, and fragments fall into the 
esophagus or larynx, giving rise to serious lesions. 
Moreover, the nitrate of silver in this form has the dis- 
advantage of creating a more decided eschar than does 
the solution, simulating the diptheritic exudation, and 
thus hindering the perception of the progress of the 
disease." 

Dr. Slade regards the tincture of chloride of iron as 
an excellent substitute for the nitrate of silver, and 
commends hydrochloric acid "in some cases," but 
forgets to tell us to what cases it is adapted. In the 
case of children, the addition of honey to the acid is 



Drug Treatment. 175 

recommended. Hydrochloric acid was a favorite top- 
ical application with M. Bretonneau, who preferred to 
employ the agent in its full strength, at long intervals, 
than to return to less energetic applications more fre- 
quently. 

Dr. Slade also mentions commendatorially as local 
applications, a solution of the chloride of soda, chlo- 
rate of potash, and the combination of chlorate of pot- 
ash and hydrochloric acid with the tincture of the 
sesqui-chloride of iron, this combination being espe- 
cially adapted to croupal cases ; and the chlorate of 
potash, we are informed, has "an undoubtedly anti- 
diptheritic influence, where time exists to bring it 
into play." 

This anti-diseaseical influence of a remedy reminds 
me of some of the celebrated preventive horse-medi- 
cines of Dr. Dadd, the veterinary surgeon, which, to 
borrow his beautifully philosophical expression, opera- 
rate anti-pathologically. 

Among the numerous other applications to the fau- 
ces which are employed and recommended by practi- 
tioners, Dr. Slade mentions strong solutions of sulphate 
of copper, chloride of sodium., tannin, capsicum, and 
Mon sell's salt. "With regard to the virtues of Monsell's 
salt Dr. Slade quotes the following testimony of Dr. 
Beardsley, of Milford, Conn. : 

" Monsell's salt was found to be the most efficacious 
and valuable of all topical remedies, affording in some 
instances decided relief. Its active astringent property 
rendered it peculiarly appropriate, and well adapted to 
obviate that relaxed and enfeebled condition of the 
throat which attends the advanced stage of the dis- 
ease." 

We have already seen that fourteen out of Dr. 



176 DlPTHERIA. 

Beardsley's fifteen cases terminated fatally, and that 
the fifteenth case was probably saved by running away 
from the doctor ; and in view of these facts, and of the 
statement of Dr. Slacle in relation to these cases, viz., 
" there was nothing peculiar in the treatment," the 
opinion of Dr. Beardsley that Monsell's salt "was 
found to be the most efficacious and valuable of all 
topical remedies," affording, in some instances, "de- 
cided relief," its astringent properties being "peculiarly 
appropriate," etc., must be taken for what they are 
worth. The efficacy, so far as results were concerned, 
seems to have been in the wrong direction. 

In cases where there is much tonsillitis, the inhala- 
tion of steam, mucilaginous gargles, and warm fomen- 
tations are recommended ; and M. Bouchat has advised 
the removal of the tonsils in the early stage of the dis- 
ease. To this tonsillitic ablation Dr. Slade raises the fol- 
lowing objections : " In the first place, the exudation is 
almost sure to re-form upon the cut surface ; next, there 
is a great risk of severe hemorrhage ; and finally, any 
cutting operation, however simple, had better be 
avoided, if possible, especially upon young children, 
and in a disease so asthenic in its character." 

For the purpose of facilitating respiration in an 
adult, in cases of great tumefaction, the removal of the 
tonsils, Dr. Slade says, " might possibly be practiced," 
by which expression I presume he means, might possi- 
bly be justifiable. 

When the nasal fossae have become implicated, 
various solutions and powders have been recommended 
to be employed by injection and by insufflation. MM. 
Bretonneau and Trosseau preferred alum. Dr. Slade 
advises chloride of soda and glycerine ; also frequent 
injections of warm water and soap as a cleansing 



Drug Treatment. 177 

process. Dr. Slade adds: "Injections of nitrate of sil- 
ver, sulphate of zinc, and, in fact, any solution which 
is applicable for the fauces, will answer a good purpose 
for injecting the nasal cavities." 

All very easy to write. But the practical difficulty 
is to find whether these things are applicable or not to 
the fauces ; and the testimony of the authors we have 
thus far quoted, leaves this matter decided both ways, 
and this is what we term proving too much, and thereby 
invalidating the evidence. 

Dr. Slade, in conclusion, gives us a summary of the 
arguments and authorities for and against the opera- 
tions of tracheotomy and tubing the larynx, which sub- 
jects I shall refer to again. 

Having thus reviewed the whole theory and prac- 
tice of Dr. Slade — whose Prize Essay gives us the 
substance of the doctrines and prescriptions of the 
medical profession in relation to diptheria — let us brief- 
ly glance at the teachings of other authors and prac- 
titioners. And first we turn to the latest author of a 
standard work on theory and practice (" Wood's Prac- 
tice of Medicine"), which work is a text-book in our 
medical schools. Dr. Wood does not agree with Dr. 
Slade, that the disease is always asthenic, requiring the 
stimulant and tonic treatment from the first. On the 
contrary, Dr. Wood regards it as sometimes of the 
opposite diathesis, and, accordingly, he recommends 
the very opposite treatment — bleeding, salts, etc. In- 
deed, the general plan of treatment recommended by 
Dr. Wood in his standard work, is the very treat- 
ment which is condemned by Dr. Slade in his Prize 
Essay. 

As an illustration of the " unanimity" which does 
not prevail in the medical profession respecting the 



178 DlPTHERIA. 

nature and treatment of diptheria, let us place the 
principles of medication advocated by these distin- 
guished authors in contrast. 

Says Dr. Wood (vol. i., p. 553) : " In the mildest 
cases little general treatment is required. The patient 
may take a dose of sulj)hate of magnesia, or some 
other saline cathartic, and should avoid animal food. 
In somewhat severer cases, with moderate fever, the 
cathartic may be repeated, and antimonials and the 
neutral mixture administered at short intervals. When 
the pulse is full and strong, blood should be taken free- 
ly from the arm, especially in adults ; but venesection 
does not exercise the same controlling influence over 
this as over the common inflammation ; at least, it 
does not obviate the tendency to the plastic affusion ; 
and, in some instances, in consequence of the feeble- 
ness of the system, is not well borne. It is generally 
quite inapplicable to those cases which occur epidemi- 
cally, or in which a dark hue or fetid odor of the exu- 
dation indicates a depraved state of the blood. When 
the symptoms are threatening, either from the general 
condition of the system or the disposition in the local 
disease to enter the respiratory passages, calomel should 
be resorted to. Under these circumstances, no general 
means of cure is so effectual as the establishment of 
the mercurial influence. If the patches should have 
reached the glottis, or be extended toward it, a full 
purgative dose of calomel should be given, and the 
medicine afterward continued in doses of from half a 
grain to two grains, every hour or two, until the mouth 
is affected or the disease relieved. Even young chil- 
dren, under these circumstances, bear calomel well 
in the quantity mentioned. Should it irritate the 
stomach and bowels very much, the dose may be di- 



Drug Treatment. 179 

minished, or the mercurial pill, and frictions with 
mercurial ointment, substituted." 

If there is anything loose, slip-shod, vague, indefi- 
nite, or ambiguous in the Prize Essay of Dr. Slade, it 
is equaled, if not exceeded, in the " Practice of Medi- 
cine" of Dr. Wood, while on the main points of treat- 
ment, these authors are diametrically opposed to each 
other. 

Dr. Wood not only recommends the depleting plan 
in many cases, but assures us that it is the very best. 
He says : " No general means of cure is so effectual as 
the establishment of the mercurial influence." 

Dr. Slade says : " The action of mercury is defensi- 
ble neither in theory nor practice." 

Dr. Wood says : " When the pulse is full and strong, 
blood should be taken freely from the arm." 

Dr. Slade says : " Depletion is not borne well in 
any form." 

Dr. Wood prescribes " full purgative doses of cal- 
omel." 

Dr. Slade replies, " Anything like purgatives should 
be sedulously avoided." 

Dr. Wood recommends the most depleting and de- 
bilitating drugs of the materia medica — neutral salts 
and antimony. 

Dr. Slade insists that such practice is always injuri- 
ous. 

Well, what is the young practitioner, or the old one, 
to do, when he goes forth to combat diptheria, with 
these high authorities in his hands ? Probably he, too, 
will compromise, and adopt partly the practice of each, 
and so do with one hand and undo with the other. 

Dr. Wood recommends, as external applications to 
the throat, leeches, rubefacients, and blisters ; and, in 



180 DlPTIIEHIA. 

relation to the internal local applications, he advises : 
" By far the most important remedies are those ad- 
dressed immediately to the part affected. By these the 
peculiar character of the inflammation, upon which its 
danger chiefly depends, may be changed ; and if the dis- 
ease has not already reached the larynx, its progress 
may be arrested. In the slighter forms, a solution of 
sulphate of zinc, containing fifteen or twenty grains of 
the salt in a fluid ounce, applied daily or twice a clay 
to the pseudo-membranous patches, will be found suffi- 
cient. When a stronger impression is required, caustic 
substances must be employed. Of these the best is 
nitrate of silver, which may be applied either in the 
solid state, or dissolved in six or eight parts of water. 
Muriatic acid is highly recommended by some writers, 
and in the worst cases is used undiluted. In those of 
slower progress, it may be diluted more or less accord- 
ing to the impression desired. Alum is another very 
efficient application. It is used in saturated solution, 
or in the form of a very fine powder, which is applied 
directly to the part by blowing it through a tube 
adapted to the purpose. These substances should be 
allowed to come in contact as little as possible with 
any other part of the surface than those covered with 
the exudation. The liquids may be applied by means 
of a large camel's hair pencil, or of a piece of sponge 
or soft linen attached to the end of a stick. In the 
intervals between the caustic applications, mucilagin- 
ous gargles, sweetened or not with honey of roses, may 
be beneficially used. A gargle made of a fluid dram 
of chlorinated soda and four fluid ounces of water, is 
recommended in cases attended with fetid discharge. 

" Howard's calomel, applied to the diseased surface 
by means of a tube, was advised by Bretonneau ; but 



Drug Treatment. 181 

its chief advantages are probably derived from the 
portion of it which may be swallowed. When the 
disease enters the nasal passages, the solution of nitrate 
of silver may be injected up the nostrils." 

In an article published in the Medical Times and 
Gazette, of Sept. 3, 1859, by Dr. J. S. Bristowe, of 
Southwark, the author is entirely opposed to the prac- 
tice so confidently advised by Dr. Wood. He says : 

" An important question is that having reference to 
the mode of treatment of the affection of the throat ; 
and I may here state, as may have been inferred from 
the perusal of my cases, that I, for one, disapprove of 
the application to the diseased surface of strong caus- 
tics and escharotics, and should prefer the employment 
in all cases of mild detergent gargles, or of warm milk, 
and such like bland and soothing fluids." 

We have already quoted the reasons which have led 
Dr. Bristowe to discard heroic applications. 

Dr. C. Swaby Smith, of Barbage, Wiltshire, gives 
his experience in the London Lancet of Sept. 10, 1859 : 
" I have tried many modes of treatment, and so far 
with very good results ; but the one that I have most 
faith in is one that I would advise those who have not 
used it, at any rate just to give it a trial. On first 
seeing my patient, I apply a strong solution of chlo- 
rinated soda to the fauces ; and follow up my treat- 
ment by ordering a sinapism to the throat ; a gargle, 
composed of solution of chlorinated soda, two ounces; 
tincture of myrrh, two drams ; water, six ounces ; to 
be used every half hour ; and in cases where the chil- 
dren are too young to gargle, I order the throat to be 
frequently washed with the same mixture by means of 
a piece of sponge. Internally, I give to an adult (of 
course varying the dose according to my patient's age), 



182 DlPTHERIA. 

chlorate of potash, two drams ; diluted nitric acid, three 
drams ; solution of cinchona (Battley's), one dram ; 
water, to six ounces ; the sixth part to be taken every 
two hours. And in cases where there is much pain in 
the limbs, I generally add a few minims of tincture of 
colchicum ; which addition has proved decidedly ad- 
vantageous ; the diet to consist of strong beef-tea, port 
wine, and, in short, all the nourishment the patient can 
take. 5 ' 

Dr. Smith is, of course, a believer in the absurd 
" respiratory food" theory of Liebig and others, or he 
would not conjoin an alcoholic stimulant with a so- 
lution of beef, under the head of diet. But I protest 
against his rule regulating the quantity of diet — " all 
the patient can take." The patient might be able to 
take a gallon a day, when he could not digest more 
than a pint. The rule for the administration of food 
should be, in all cases of diptheria, whatever the patient 
can use. Food is only beneficial as it is assimilated, 
not according to the quantity swallowed. 

Dr. Smith's concluding remark casts a shade of sus- 
picion over the supposed beneficial effects of his pun- 
gent gargles, etc. " Although these means are un- 
doubtedly useful in decided cases of malignant sore 
throat, they are far too active to be resorted to in 
simple cases, as they would only tend to aggravate the 
symptoms." 

My own explanation is this : These " active means," 
or strong applications, which aggravate the symptoms 
in mild cases, do not benefit the malignant cases ; but 
because of the less degree of vital resistance to the 
drugs in the malignant cases they seem to be well 
borne, and the practitioner is deluded into the notion 
that they are useful. 



Drug Treatment. 183 

Prof. Clark condemns, in the strongest terms, the 
depleting and cauterizing treatment so strongly recom- 
mended by Prof. Wood and others, and relies almost 
entirely on the stimulating plan ; and his summary of 
the conflicting opinions of various authors and prac- 
titioners, if it does not prove how diptheria ought to be 
treated, at least shows how little reliance can be placed 
on medical experience and testimony. I quote entire 
what he says of the treatment of this disease in con- 
cluding his lectures on the subject : 

" There is no established treatment for diptheria. 
In saying this, I speak of the whole treatment, for I 
think one rule in the management of diptheria is as 
well established and as generally insisted on as any in 
medicine — that is, to sustain the patient's strength by 
food, tonics, and often by stimulants, during the whole 
course of the disease, and to do this in the face of every 
difficulty. This rule is not an arbitrary one, but is the 
result of an extended and almost uniform experience 
in Europe and in this country. Many physicians, in 
their early acquaintance with the disease, have adopted 
the opposite plan, but have found that bleeding and 
depressing agents generally could not be safely per- 
sisted in. Bretonneau, in his second memoir, read 
before the Academy of Medicine in Paris in 1821, is 
very explicit on this point. He says (p. 4) : i With 
regard to Epidemic Croup, I am compelled to declare, 
contrary to the generally received principle, that 
abstraction of blood has appeared to me hurtful, and to 
accelerate the propagation of diptheritic inflammation. 
Emetics and blisters have been used without relief; 
and I can assert that these means have not been omit- 
ted in the greater number of patients who have died. 5 
1 1 have not abandoned it [depletion] without hesita- 



184: DlPTHERIA. 

tion (though it was condemned by the physicians of 
the seventeenth century) ; I have been compelled, 
nevertheless, to yield to evidence, seeing so frequently 
the opposite of that which I had hoped. I am certain 
that the symptoms of croup [tracheal diptheria], so far 
from being retarded, have several times manifested 
themselves immediately after the application of leeches, 
applied for the purpose of preventing this fatal disease, 
the fear of which had been excited by a very slight 
sore throat. I am now astonished that I did not sooner 
understand that sinapisms, pediluvia, and irritant in- 
jections were measures which were not appropriate to 
the nature of the disease, and were without proportion 
to its severity.' 

" Dr. Turner, of Petersburgh, Ya., has given us his 
experience with this plan of treatment (Am. Med. 
Times, Dec. 8, 1860) : ' Depletants, mercurial alter- 
atives, leeches, blisters, caustics, and common sage 
gargle, constituted my treatment when I first encount- 
ered diptheria.' 'Those patients in whose treatment 
I employed mercury and local depletants fared the 
worst.' ' I soon determined that the disease was ulti- 
mately asthenic, and from this fact I derived the basis 
of what I consider sound treatment.' In this experi- 
ence of M. Bretonneau and Dr. Turner you have an 
account of what has occurred in the observation of 
many a sound practitioner, and of what will happen to 
you, I doubt not, unless you begin where such men 
end, in an entire abstinence from depletory measures, 
whether general or local. You have but little tempta- 
tion from the examples of American physicians to ab- 
stract blood, because we had been apprised of what our 
European brethren had learned about it, long before 
the disease reached us. But knowing what power is 



Drug Treatment. 185 

ascribed to blood-letting in the management of inflam- 
mations, you would be almost forced to a trial of it 
unless you are informed liow worse than useless it has 
been found by those who have preceded you. We 
may say, then, that general sanguineous depletion is 
forbidden in diptheria, and if local bleeding is ever 
admissible it is only in exceptional cases. I will 
give you one quotation more in support of this state- 
ment from one of the high authorities on this disease. 
Trosseau (Mems., p. 241) says : ' If diptherite did not 
differ from simple inflammations in its form, its prog- 
ress, its dangers, and, in a word, in numerous charac- 
ters which make it altogether a special disease, it 
might be supposed that antiphlogistic treatment would 
be serviceable ; but we may conceive, d priori, that 
blood-letting and emollients would have no favorable 
influence, and experience has confirmed what analogy 
had led us to surmise. It is in vain to attempt to cure 
diptherite by means of the antiphlogistic regimen. 
The inflammatory complications may be subdued, and 
yet the disease remains without losing any of its malig- 
nity.' If we can not inherit the wisdom of those who 
precede us, we can at least profit by their learning. 
It is for that reason I have taken time to place this 
important point fully before you. 

" Diptheria is not a ' self-limited disease,' in the 
sense in which scarlet fever, measles, and small-pox 
are said to be self-limited, yet it has a duration, vary- 
ing much in different cases, but which rarely exceeds 
twenty days for the membranous and most dangerous 
period. If death does not occur in three, five, seven, 
ten, or twenty days in the different varieties and forms 
of the disease, we look for recovery. If we can sustain 
our patient through these trying periods, however 



186 DiPTHERIA. 

varying, we have done much to insure his recovery. 
The virulence of the disease has exhausted itself, or at 
least its power to destroy is greatly diminished. 
What an eminent medical writer has said of typhus, can, 
I think, with equal truth be asserted of the constitutional 
management of diptheria : ' Our treatment can only be 
of benefit in an indirect manner, that is, in concert 
with the salutary efforts of the vital powers.' Exclud- 
ing, for the present, considerations relating to local 
applications, I may go further and say of this disease 
what Dr. Stokes says of fever : ' We can not cure 
fever. N"o man ever cured fever. It will often cure 
itself. * * * We prevent dying of exhaustion by 
food, by the use of stimulants and tonics. * , ■' * - * 
We seek to preserve the patient at the least expense to 
his constitution up to the time when, by natural laws, 
the disease will spontaneously subside.' Here for 
' fever,' read diptheria / transpose the words c stimu- 
lants and tonics,' so as to give the higher position to 
the latter ; then, even without reservation in favor of 
local applications, I believe you have found the great 
fundamental fact in the treatment of diptheria. I do 
not wish to say, however, that the rigid enforcement 
of this important rule for twenty days will always be 
sufficient, or to say that in every case the dangers are 
all passed in that time. I have known the death of a 
child to occur thirty days after the first appearance of 
the membrane in the throat, and fully three weeks 
after the exudation in the larynx and trachea had been 
fully cleared away. Yet this I believe is but one case 
in a hundred. In general, among the very worst cases, 
those who have passed the dangers of the first three 
weeks recover. But the rule of treatment is applic- 
able with modifications to the cachexia which often 



Drug Treatment. 187 

follows the bad cases, and to the paralytic affections 
which, though they are but little dangerous to life, are 
prolonged for weeks and sometimes for months. Hav- 
ing impressed, as I hope, these leading doctrines upon 
your minds, that blood-letting, both general and local, 
has been tried in vain ; that active cathartics do no 
good ; that emetics are worse than useless, except for 
a special purpose to be mentioned by-and-by ; that 
revulsives can accomplish nothing advantageous ; in 
a word, that debilitating treatment but plays into the 
hands of the disease, if I may be pardoned the expres- 
sion ; and that all perturbating general treatment is 
forbidden ; but that food, tonics, sleep, and stimulants 
(when needed) are the true antagonistics of diptheria — - 
we will now try to appreciate the value of the local 
treatment, and determine, if we can, whether we pos- 
sess any agents which have power to prevent or con- 
trol its justly dreaded local manifestations. 

" Here, if I yield to my own convictions, I must say 
we pass from the certain to the doubtful. It is with 
reference to these local applications that we are com- 
pelled to say that diptheria has no established treat- 
ment. If we ask whether nitrate of silver, muriatic 
acid, or any other caustic can stop the progress of this 
membranous disease of the throat, we shall obtain con- 
tradictory answers. Bretonneau answers, yes — a thou- 
sand times yes. Trosseau answers, yes ; Guersant 
answers, yes. Indeed, there is a confidence in the 
power of these agents among the French physicians, 
whose opinions are best known to us, that is all but 
overwhelming. There is a persuasion in their eloquent 
praises and reiterated assurances that has forced me to 
doubt my own experience ; and when disappointed in 
the effects of these agents, to return to them again and 



188 DlPTHERIA. 

again in the hope that, by a closer imitation of their 
methods, I might participate in their triumphs. 

" Among our own physicians I know some whose 
faith in the saving virtues of a timely and efficient ap- 
plication of these substances is not dimmed by a single 
doubt. I have a friend, judicious and observing, who 
can not convince himself that the throat membrane 
can ever resist the free application of solid nitrate of 
silver, or a solution of it, one hundred and twenty 
grains to the ounce of water, when it is used early and 
often. Dr. Woodward, of Brandon, Vermont, believes 
that he and his friend Dr. O'Dys owe a portion of 
their success (sixty cases without a single death) to the 
early use of this agent. This, and alterative doses of 
mercurials, were their main reliance ; and he seems to 
suppose that if the disease, which was so fatal in a 
neighboring town, had been treated in the same way, 
the results would have been more favorable. On the 
other hand, while the English physicians generally are 
far behind the French in their praise of caustic appli- 
cations, many, like Greenhow, object to them alto- 
gether, except in particular conditions. Greenhow's 
language is worth quoting: 'Local treatment applied 
to the throat internally has been almost universally 
adopted in the treatment of diptheria ; and, though I 
by no means deny its value when judiciously em- 
ployed, I am sure much mischief has been produced 
by its indiscriminate use, etc. * ■ * . * Observing 
that the removal of the exudation, and the application 
of remedies to the subjacent surface, neither shortened 
the duration nor sensibly modified the progress of the 
complaint, but that the false membrane rarely failed 
to be renewed in a few hours, I very soon discontinued 
this rough local medication.' When, however, the exu- 



Drug Treatment. 189 

elation is all within sight, and the surrounding parts 
are healthy, he thinks it proper to apply solid nitrate 
of silver, or nitric or muriatic acid, for he says : 4 It is 
just possible in such cases that this treatment might 
check the progress of the complaint, and lead to a 
rapid recovery.' (Diptheria, pp. 263-4-5.) Dr. Tur- 
ner, of Virginia, referring to similar applications 
{American Medical Times, Dec. 18, I860), says: 'I 
studiously avoid probangs ; I look upon them as in- 
struments of torture and death. I know I have seen 
cases that died from the constant mopping to which 
the throat was subjected.' Dr. Metcalfe, of this city, 
says of the application of nitrate of silver to the 
throat (American Medical Times, Aug. 25, 1860), that 
lie can not say he has derived any benefit from it. In- 
deed, in my intercourse with the physicians of this 
city, I meet but few who have not tried it, and disap- 
pointed in its promised benefits, have abandoned it. 
My own observation has taught me that the false 
membrane will not fall off by the mere application of 
nitrate of silver, either on the exudation or on the sur- 
rounding parts, without the use of some mechanical 
force ; and that its application to tissues, after forced 
or spontaneous removal, will not prevent the reproduc- 
tion of the exudation, at least in numbers of instances. 
I have seen the membrane appear when it was not 
looked for, in the course of scarlet fever for example, 
and where the nitrate of silver had been systematically 
applied for what appeared to be a different kind of 
sore throat. Yet, in these cases, it has sometimes fol- 
lowed upon the very heels of that medication. Such 
facts as these, however, do not prove that the applica- 
tion of the nitrate of silver is useless. They destroy 
our faith in its unfailing virtues, and fairly raise the 



190 DlPTHERIA. 

question, whether this kind of treatment is useless, 
cruel, and to be abandoned ; or if failing in many, it 
really saves the lives of some. This doubt I can not 
solve for you. I can only say that my faith in the 
curative powers of all caustic applications is greatly 
shaken. But they are proper applications so long as 
there is any ground left for faith in them. That you 
may know how to use them, not from a doubter like 
myself, but from one whose confidence in the nitrate 
of silver, as the representative, and the best of them 
all, illuminates almost every page of ample memoirs, 
I shall quote again from Bretonneau. In his earlier 
memoirs, he recommends hydrochloric acid, diluted 
with three parts of honey ; he even used this acid con- 
centrated and pure. Powdered alum was also a fre- 
quent application. In his fifth memoir, he modifies 
his former statements (p. 192 and onward): 'Of the 
local applications employed to modify the Egyptian 
ulcerations, there are none so painful as alum and hy- 
drochloric acid, while a solution of nitrate of silver is 
less painful and more efficacious ;' and he gives the 
credit of first suggesting it to Dr. Mackenzie, of Glas- 
gow. ' On the first day of the appearance of the 
Egyptian chancre (meaning here tonsillar diptheria) a 
radical cure can be obtained in forty-eight hours.' 'It 
is sufficient to employ on the first day two local appli- 
cations — one in the morning and one in the evening ; 
and to repeat the proceeding the next day.' The 
sponge used for the application should be moistened, 
not soaked. When the disease has passed into the tra- 
chea, the sponge should be applied with gentle press- 
ure to the opening of the larynx, the epiglottis being 
held pitilessly forward. ; After a few minutes' respite, 
the same proceeding must be repeated in all its details, 



Dkug Treatment. 191 

the sponge having been washed, wiped, and dried, by 
pressure of a very dry piece of linen.' He relates the 
case of a child three years old, in which a membrane 
that was raised was a cast of the larynx, and its broken 
bronchial extremity bad an alarming thickness, such 
as to forbid tracheotomy, but in which four applica- 
tions in this way, each repeated (eight each day), were 
practiced. ' From the fourth day all anxiety ceased.' 
' I affirm that without error in calculation, a solution 
of thirty-two grammes (four hundred and ninety-four 
grains) of the crystallized nitrate of silver was com- 
pletely employed in this horrible treatment.' Two 
thirds at most being wasted ; 4 yet the rest was in 
great measure mingled with the mucous matter drawn 
in at the time of the cauterizations.' The linen washed 
and dried in the sun showed, by the black spots upon 
it, that unusual quantities of the salt had been swal- 
lowed. 

" When the disease is detected in the nostrils, he ad- 
vises to inject a solution of nitrate of silver with a 
padded syringe; and to inject both nostrils, especially 
if there is the least swelling of the neck glands on the 
two sides. Bretonneau does not inform us regarding 
the strength of the solution which he prefers, but the 
common practice is to make it forty to one hundred 
and twenty grains to the ounce of water." 

Dr. Winne gives us the most promiscuous jumble of 
drug-medication extant, and as the best specimen of its 
kind I put it on record. If it does not convince the 
reader that the prevalent practice in diptheria is a 
series of blind experiments on the vitality of the pa- 
tients, I know of no evidence that will be likely to 
do so. 

"The local treatment consists chiefly in the applica- 



192 DlPTIIERIA. 

tion of caustic and astringent substances, in one form 
or another, to the affected part. Of these, the most 
usual are nitrate of silver, either solid or in solution, 
powdered alum, chloride of lime, chloride of soda, ses- 
qui-chloride of iron, and hydrochloric acid. 

" Mr-Breton neati almost invariably employed the last 
of these remedies as a local application in his own 
practice, with the most marked success. The hydro- 
chloric acid may be employed very nearly of the 
strength of the dilute acid of the shops, or consider- 
ably reduced in strength— dependent upon the severity 
or mildness of the attack. The best method of apply- 
ing it is to moisten a small sponge attached to a pro- 
bang or a camel's hair pencil with the fluid, and while 
depressing the tongue with the left hand, to carry the 
brush forward with the right, until the fauces are 
reached, when those parts of the tonsils, uvula, or soft 
palate on which the membranous deposit, appears, may 
be moistened with the fluid, and the instrument with- 
drawn. The hydrochloric acid should be applied not 
only to the membranous surface, but to the parts im- 
mediately surrounding it, by which means the spread 
of the membrane is often arrested. The application 
should be renewed several times a day. Care, how- 
ever, must be taken not to apply it of too great 
strength, or too often at the onset of the disease, espe- 
cially if the symptoms are not of an aggravated char- 
acter ; otherwise the local disease may be enhanced, 
by the unnecessary injury inflicted upon the surround- 
ing parts. The symptoms often appear momentarily 
aggravated by the local application, which is not un- 
frequently followed by an attempt to dislodge the 
membrane by vomiting. Should this latter result fol- 
low, the tonsils and palate will appear as if shrunken 



Dkug Treatment. 193 

in substance, and spotted here and there with a few 
drops of blood upon the surface formerly occupied by 
the membrane. 

" When this does occur, the application may be re- 
newed directly upon the surface of the gland, in order 
to arrest the almost invariable disposition of the mem- 
brane to renew itself upon the abraded part. As the 
disease progresses, and the membrane extends toward 
or into the pharynx, the difficulty in making local ap- 
plications becomes greatly enhanced ; but the practi- 
tioner should not hesitate, for fear of inflicting tempo- 
rary pain, from thoroughly exploring and covering the 
parts affected with the solution of hydrochloric acid. 
For the purpose of effecting this, it is often necessary 
to place the head of the patient upon the knee of an 
assistant, and with a spatula to depress the tongue and 
the lower jaw firmly at the same time, by which means 
a view of the whole fauces may be obtained, and an 
opportunity afforded of making a thorough application 
of the local remedy. 

" Nitrate of silver has been warmly recommended 
by Trosseau, Guersant, and Yalleix, in France, and 
was the application almost universally resorted to in 
England at the commencement of the epidemic in that 
country. The usual mode of using nitrate of silver in 
England was in solution. Dr. Kingsland advised a so- 
lution of 16 grains to an ounce of distilled water ; and 
Dr. Hart, 30 grains to an ounce of distilled water. The 
mode of its use resembles that of the hydrochloric acid. 

" When the local application of nitrate of silver is 
made in a solid form, care should be taken that it does 
not slip from the holder, or break, as in such an event 
it might fall into the stomach. Such an accident ac- 
tually happened to M. Guersant ; fortunately, how- 

9 



194 DlPTHEKIA. 

ever, the stomacli rejected it ; but this might not 
always occur, and few medical men would be willing 
to take so hazardous a risk. Dr. Hauner, of Austria, 
considers nitrate of silver as the very best local appli- 
cation to the diseased surface, and advises its use in a 
solution of from a scruple to half a dram, to an ounce 
of water. 

" Subsequent experience did not confirm the good 
opinion entertained for nitrate of silver among the 
English practitioners, and many who were at first loud 
in its praises came to disuse it altogether. A substi- 
tute for this was found in the sesqui-chloride of iron, 
which is recommended by Dr. Ranking as being very 
efficacious in its effects upon the false membrane. He 
advises its use in the form of a gargle, of the strength 
of two drams to eight ounces of water, to be applied 
to the throat by means of a brush. 

" In the United States, opinion appears to be divided 
as to the best local application. Dr. Blake, of Sacra- 
mento, has found the greatest benefit resulting from 
an application of strong hydrochloric acid ; a view in 
which he is sustained by Dr. Bynum and Dr. Thomas, 
both of whom have had much experience in the treat- 
ment of the disease. Prof. Comegys, of Cincinnati, is 
in the habit of applying nitrate of silver, either in 
substance or strong solution in water. Sometimes, 
when the ulcerations are deep, he touches them with 
strong nitric acid, by means of a brush. In some cases 
he has employed with considerable benefit inhalations 
of tannic acid dissolved in sulphuric ether, applied by 
means of a cloth wetted with it, to the mouth. The 
formula is : 

Jfc. — Tannic acid f. 3ij- 

Sulph. ether f. ?j. M. 



Drug Treatment. 195 

" Dr. Jacobi, of New York, who, as physician to the 
Canal Street Dispensary, which treats a large number 
of German children, has had a very large experience, 
says : 

" c The local treatment consists of cauterization of 
the membranes and surrounding parts with the solid 
nitrate of silver, or with strong or mild solutions of 
the same salt in water (jss-j. : fj.) ; of gargles, consist- 
ing of solutions of (or applying in substance) astrin- 
gents, such as tannic acid, alum, sulphate of zinc, or 
claret wine ; in gargling with, er applying, such me- 
dicinal agents as are known to have some effect on the 
constitution and tissue of the pseudo-membranes, as 
chloride of potassium, chlorates of potassa and soda, 
diluted or concentrated nitric or muriatic acids, liquor 
of sesqui-chloride of iron, etc. Astringents will pre- 
vent maceration, render the exudation dry and hard, 
and alter the consistency of the surrounding hypersemic 
and edematous tissue. It will thus prevent, sometimes, 
the extension of pseudo-membranes to the neighbor- 
hood of the parts already affected, and in some cases 
may accelerate the expulsion of the membrane as a 
whole. We have thus seen the best effects from tan- 
nic acid, either applied directly to the parts by means 
of a curved whalebone probang, or dissolved in water 
as a gargle (3ss-ii. : ?i.) Of the tinct. sesquichlor. iron 
we have seen no particular effect. Cauterizations with 
nitrate of silver we have found to be generally of very 
little use when applied to the pharynx. Its effect is 
superficial only ; it will form a scurf, but will destroy 
nothing. Destruction of the parts can not be effected 
except by forcing the caustic into and below the mem- 
brane ; this can seldom be done in the pharynx of 
children, and for this reason cauterization is unavailing 



196 DlPTHERIA. 

at this point, but will prove beneficial, we believe, by 
confining the process of exudation to its original local- 
ity. In cutaneous diptheria cauterization may be 
exercised to its full extent ; but as these cases are gen- 
erally attended with extreme prostration, the general 
treatment will prove both more necessary and success- 
ful. If cauterization is to be resorted to, we generally 
use, and with good effect, more or less concentrated 
muriatic, or acetic, or nitro-muriatic acid. Where, 
however, cauterizations are made, great caution is 
necessary not to mistake afterward the result of the 
caustic for pseudo-membrane. This remark is partic- 
ularly applicable where nitrate of silver has been used.' 

" Alum, chloride of lime, and calomel are sometimes 
recommended. When their use is deemed advisable, 
they may be applied by dipping a brush or the finger 
in the dry powder, and carrying it directly to the 
affected part, or blowing them through a quill. 

" Prof. Metcalfe advises the use of the bromide of 
iodine, in the form of two drops to an ounce of the 
mucilage, or gum-arabic, as a topical application. He 
also gives dram doses of this mixture internally, with 
the happiest results. 

" When there is a considerable accumulation in the 
nares and behind the velum, the debris and foul secre- 
tions may be removed, and much temporary relief 
obtained, by an injection of an infusion of chamomile 
with a few drops of creosote, which may be best 
effected by a laryngeal syringe. The syringe of Dr. 
Warren, of Boston, answers a very good purpose for 
injecting fluid either into the nares or below the 
epiglottis. It, however, is liable to the objection that 
it is likely to produce irritation, by coming in contact 
with the irritable portion, exactly at the opening of 



Drug Treatment. 19 7 

the glottis, which is found, by the researches of Prof. 
Horace Green, to be the seat of sensibility, instead of 
the epiglottis, as has heretofore been supposed. The 
common glass syringe, with either a curved extremity 
or a straight one — dependent upon the part to be 
reached — answers all ordinary purposes, and possesses 
the advantage of being easily obtained at the apothe- 
cary's, and is of slight cost. 

" For correcting the fetor of the secretions, the 
chloride of soda, in the proportion of one dram to six 
ounces of water, may be used with much benefit. Dr. 
Ranking suggests, on the supposition of the presence 
of some vegetable parasite, the use of sulphurous acid 
and hyposulphate of soda, in the form of a saturated 
solution. ' The power of the latter.' he adds, ' in 
destroying the fungoid growth of favus, as well as the 
oidium which infests the vine, I have myself experi- 
enced ; and I strongly recommend it, provided the 
vegetable origin of diptheria be confirmed by further 
observations.' 

u Much relief is often afforded by inhalation, espe- 
cially after the second or third day of the attack. An 
excellent means of fumigation is to pour boiling water 
upon catnip, or the leaves of any similar plant, with 
the addition of a little vinegar, and to allow the patient 
to inhale the fumes, either by inclosing the head under 
a blanket, or by applying the mouth to a tube con- 
nected with a close vessel containing the materials 
from which the vapor is generated. The immediate 
effect of fumigation is extremely grateful to the 
patient. Dr. Gurdon Buck advises the addition of 
Labarroque's solution of the chloride of soda, in suc- 
cessive portions of a teaspoonful each, to the liquid 
used for fumigation. Mr. C. T. ITodson recommends 



198 DlPTHERIA. 

the inhalation of boiling water, to which has been 
added a tablespoonful of chlorinated lime. 

u General Treatment. — The general treatment must 
be regulated by the type of the disease. Shortly after 
the appearance of M. Bretonneau's treatise, a great 
variety of treatment was recommended by different 
practitioners, all, however, with a view to arrest in- 
flammatory action. Leeches to the neck, counter-irri- 
tation, especially by means of blisters, active mercuri- 
alization, and purgative medicines furnished the basis 
of most of the plans advised. Calomel, especially, 
obtained great celebrity, and was at one time con- 
sidered as the most effective remedy in arresting the 
progress of the disease. It was first prescribed by Dr. 
Conolly, who was residing at Tours, at the appearance 
of the disease ; and was so efficient in his hands, in 
minute doses, as speedily to find favor with the French 
practitioners. But, whatever may have been the suc- 
cess attendant upon its administration at that time, it 
is now found to require great caution in its use. 

" Blisters are contra-indicated, and so far from fur- 
nishing relief, tend to increase the danger, by assum- 
ing an unhealthy, and frequently sloughy, appearance. 
The bites of leeches often give rise to passive bleeding, 
extremely difficult to arrest, which greatly reduces the 
already exhausted energies of the patient. Everything, 
in fact, which tends to lower the powers of life, or in- 
duce prostration, should be sedulously avoided, in the 
type of disease which at present prevails ; and cer- 
tainly differs from that for which Bretonneau, Conolly, 
and other medical men in France at that period were 
called upon to prescribe. 

" The type of the disease as it now prevails exhibits 
a tendency to extreme prostration from the very begin- 



Dkug Treatment. 199 

ning, and requires a tonic treatment to sustain the pa- 
tient. The most effectual method of accomplishing 
this is by means of quinine, the various preparations 
of iron and steel, stimulants, in the form of brandy, 
milk punch, and wine whey, and a generous diet, con- 
sisting of beef-tea, Liebig's extract of meat, and a 
strong decoction of coffee. Sulphate of quinine may be 
administered in grain doses, conjoined to two grains of 
the sulphate of iron, repeated as often as the symptoms 
appear to require — usually every three hours. It is 
w r ell to alternate this remedy with doses of chlorate of 
potassa, which appears to exercise a beneficial influence 
upon the disease of the mouth and throat. Chlorate of 
potassa may be given in doses of from five to ten grains, 
in distilled water, or a bitter infusion. Prof. Barker, 
of New York, advises the chlorate of potassa, in doses 
from 3ss. to jj. The chloride of soda has been recom- 
mended with the same intention, but does not appear 
to be equally efficacious with the chlorate of potassa. 

" The tincture of the sesqui-chloride of iron has met 
with much favor among the English practitioners, as a 
tonic. Dr. Ranking gives it the preference to other 
tonics, although he frankly admits that it matters but 
little which of this class of medicines is used, provided 
the strength of the patient be sustained. ' Personally,' 
he remarks, 'X give the preference to the tincture of 
the sesqui-chloride of iron, not only from the inference 
drawn from the analogy of its unquestionable useful- 
ness in the more asthenic forms of erysipelas, but also 
from the positive evidence of its benefit derived from 
the experience of several gentlemen in the country, 
among whom I may mention Mr. Dix, of Smallburg; 
Mr. Prentice, of North Walsham ; and Mr. Cowles, of 
Stalham ; each of which has had unusual opportuni- 



200 DlPTHERIA. 

ties of testing its advantages.' The tincture of the 
sesqui-chloride of iron may be administered in doses 
of from eight to sixteen drops, in a little water. 

" Whatever may be the success or ultimate failure of 
this remedy, its first introduction into the treatment of 
this disease is undoubtedly due to Professor Thomas P. 
Heslop, of Queen's College, Birmingham, who, after 
repeated trials in his own practice, brought it to the 
attention of his clinical class at Queen's Hospital and 
the Medico-Chirurgical Society of Queen's College. 
His own success appears truly astonishing. 'I have 
given in this disease,' he says, ' to an adult twenty-five 
minims of the London tincture of the sesqui-chloride 
of iron every two, three, or four hours, and have con- 
joined a few drops of dilute hydrochloric acid. I have 
also applied daily, sometimes twice a day, by means 
of sponges, a solution of hydrochloric acid, but little 
weaker than the dilute acid of the London Pharmaco- 
poeia, and have always enjoined the regular use of 
weak gargles of the same acid. This, with the con- 
stant administration of stimulants, beef-tea, milk and 
jellies, has constituted my treatment; and I repeat 
here, what I have already stated in other quarters, that 
since I have become aware of the value of this medi- 
cation, nearly ten months, I have not lost one case.' 
An excellent formula for administering a combination 
of chlorate of potassa and the sesqui-chloride of iron 
is : Chlorate of potassa, from eight to twenty grains ; 
tincture sesqui-chloride of iron, ten to twenty-five 
drops ; rose-water or orange-syrup, one dram ; water, 
four ounces. Where there is difficulty in administer- 
ing medicine, the bulk may be reduced by omitting 
the water altogether, and increasing at pleasure the 
amount of syrup. The success which has attended the 



Drug Treatment. 201 

use of this remedy in England warrants a careful trial 
of its merits at the hands of practitioners in the United 
States. 

" Where the disturbance of the secretions appears 
to indicate the use of mercurial preparations, and they 
are not positively contra-indicated by the depressed 
state of the patient, calomel may be administered, in 
doses of one tenth of a grain, mixed with sugar, and 
placed dry upon the tongue. Dr. Bigelow has found 
this remedy valuable in the disease as it prevails at 
Paris ; and Mr. Thompson was equally successful wdth 
it at Launceston, England. Dr. Anderson, of New 
York, and Dr. Briggs, of Richmond, have employed 
calomel with marked benefit. It is a question, when 
calomel and chlorate of potassa are administered con- 
jointly, whether the effects of the potassa do not en- 
tirely annul those of the calomel. Dr. Bigelow, as 
the result of some very recent observations, says, that 
although it may retard or prevent the specific effects 
on the salivary glands, it does not in any way modify 
its action upon the secretions. It may be well, how T - 
ever, when the effect of the calomel is important, to 
intermit the use of chlorate of potassa for twenty-four 
hours, or to alternate the use of these medicines at 
wide intervals between the administration of the 
two. 

" Emetics are serviceable when portions of the de- 
tached membrane are lodged in the throat, without 
being expelled, or when the disease is making rapid 
progress, and threatens to invade the larynx. The ac- 
tion of the emetic in this instance is frequently to de- 
tach the pellicle and dislodge the pseudo-membrane. 
At the same time that the membrane is thus ejected, 
the throat is relieved of the foul secretions which 

9* 



202 DlPTHEEIA. 

might otherwise be received into the stomach, to the 
great detriment of the patient. 

" But, whatever treatment may be adopted, the fact 
should never be lost sight of, that the system is labor- 
ing under the influence of a powerful and most de- 
pressing poison ; and it matters but little, so far as the 
constitutional treatment is concerned, whether this 
poison be at first local, and afterward disseminated 
through the system, or is from the beginning of a gen- 
eral character, and incidentally developed in the mu- 
cous membranes of the air-passages. In the perform- 
ance of her functions in the elimination of this poison, 
Nature requires to be sustained, not only by the free 
use of the tonics already indicated, but by a liberal 
allowance of the most concentrated and nutritious ar- 
ticles of diet, in which beef-tea, milk, eggs, brandy, 
wine, and coffee stand prominent. When there is 
difficulty in swallowing, not only these articles of diet, 
but quinine, may be introduced, by means of injec- 
tions ; a resort to which should not be deferred until 
it is impossible to administer medicines by the mouth, 
but whenever the difficulty of swallowing becomes at 
all a prominent feature in the complaint. Injections 
should not be administered in greater quantities than 
two ounces at a time, and should not be often re- 
peated ; otherwise they will give rise to a local irrita- 
tion in the rectum, which will prevent their retention. 
One or more drops of tincture of opii, according to the 
age of the patient, will greatly aid in the retention of 
the injection. 

" After the violence of the disease has been checked, 
a continuance of the tonic treatment should be per- 
severed in for some time, not only to prevent the se- 
quelae liable to follow, but a recurrence of the attack, 



Drug Treatment. 203 

which often reappears after an interval of several 
weeks, especially when the patient is exposed to those 
depressing influences which are too frequently attend- 
ant npon poverty and uncleanliness." 

We have now seen what " confusion worse con- 
founded" exists in the medical profession with regard 
to the treatment of diptheria, and how the testimony 
of medical men of equal character and experience is 
hoihfor and against all plans of drug treatment which 
have yet been adopted. Some recommend the stim- 
ulant treatment; others prefer the antiphlogistic; 
some rely mainly on cauterizing the throat; others 
declare caustics to be injurious ; some object to any 
strong local applications because the disease is consti- 
tutional ; others object to powerful constitutional 
treatment because the disease is local, etc. And I will 
conclude this " budget of blunders" with a few quota- 
tions from the latest authors, showing that the dis- 
crepancies among physicians are still as wide and 
irreconcilable as ever. The especial object I have in 
view in dwelling so long on drug-medication is to 
destroy all confidence in it ? and I know of no more 
effectual method of discrediting the system than that 
of telling the people what its advocates allege in its 
favor. 

Dr. A. C. Hamlin, Surgeon to the Second Regiment 
Maine Volunteers, reports a case in which his treat- 
ment was chlorate of potash, gargles, iodine embroca- 
tions externally, inhalations of steam, and carbonate 
of ammonia and brandy, with high diet, internally ; 
also cauterization with solid nitrate of silver ; pieces 
of ice held in the mouth frequently ; sponge baths, 
stimulants, etc, In detailing the plan and effects of 
treatment, Dr. Hamlin makes the significant statement, 



204 DlPTHERIA. 

that after the cauterization the disease increased in 
both tonsils, and that, on applying the ice, there was 
an immediate improvement, a circumstance the import- 
ance of which we shall be better enabled to understand 
after we have examined the rationale and effects of 
Hygienic treatment. 

Dr. Minot, Secretary of the Boston Society for Med- 
ical Improvement, has reported in the Boston Medical 
and Surgical Journal for March 21, 1861, the practice 
of several members of the Society : Dr. Lyman treated 
a case with chlorate of potash, fever mixture, solid 
nitrate of silver to the throat, castor-oil, wine, beef-tea. 

Dr. Fifield stated that, in the cases he had seen, the 
application of solid caustic seemed to aggravate the 
disease, as did also the tincture of iodine. 

Dr. Ainsworth prescribed strong solution of nitrate 
of silver, chlorate of potash, diluted muriatic acid, 
mustard to the throat and neck, citrate of magnesia, 
solid nitrate of silver, broth, flax-seed tea, strong solu- 
tion of capsicum, per-chloride of iron, enema of strong 
beef-tea w T ith Madeira wine, and wine by the mouth. 

Dr. Minot reported a case in which u the treatment 
consisted in the administration of tonics, stimulants, 
and concentrated nourishment." 

By " concentrated nourishment" the Doctor probably 
means diluted slops, broth, beef-tea and wine, brandy 
and toddy, of which we have already seen quite 
enough. 

Dr. Jackson reported cases treated with quinine and 
muriate of iron internally, and muriatic acid to the 
throat. He states that nitrate of silver was at first 
applied to the throat, but seemed to do harm. An 
emetic and cathartic generally preceded the above 
treatment. 



Drug Treatment. 205 

Dr. Tower, of South Weymouth, Mass., in a com- 
munication to Dr. Bowditch, published in the Boston 
Medical and Surgical Journal for March 7, 1861, says : 

" The treatment which I have pursued has been 
various, but that which has found most favor with me 
is the free and frequent exhibition of chlorate of 
potassa ; gargles of the same, or of water acidulated 
with muriatic acid, or, what is still better, a solution 
of common salt. The best external application is a sat- 
urated solution of common salt. I say this after trying 
various rubefacients and cataplasms. Cold water is 
employed by some, but I have never used it. If the 
disease is not arrested by these applications, I make 
use of a strong solution of nitrate of silver (ji. to fi.). 
When there is much prostration, stimulants, tonics, and 
plenty of beef-tea, or other nourishment." 

Dr. W. A. Bryden, of Mayfield, in the British Med- 
ical Journal for Nov. 21, 185T, gives us his plan of 
treatment, which consists essentially in the use of 
guaiacum and chloride of potash, instead of the appli- 
cation of the solid nitrate of silver, which he regards 
as injurious. 

Dr. Ramskid, of the Metropolitan Free Hospital, 
objects to strong caustic because, " in more than one 
case, it has seemed to increase every undesirable symp- 
tom." This plan of treatment is thus given in the Lon- 
don Lancet for Feb. 19, 1859, with a case to illustrate : 

" A., a young lady, aged 15, of good condition in 
life, robust, and not subject to any of the influences 
supposed to be favorable to the development of the 
disease. I saw her on the third day, and found her in 
bed, tranquil, capable of speaking a few words together, 
breathing comfortably without noise, swallowing freely 
and without pain anything given to her ; with a cool, 



206 DlPTHERIA. 

soft skin, and silky pulse, beating 100. The submax- 
illary and cervical glands were much swollen. She 
could open her mouth tolerably well, and by means 
of a spoon a very distinct view of the interior was 
obtained. The soft palate was projecting, strongly 
convex on to the base of the tongue ; the swelling 
eased off gradually, terminating on the hard palate, 
within half an inch of the front teeth ; it was covered 
in patches with the characteristic false membrane, and 
everywhere exuded copiously a jelly-like, tenacious 
fibrin. By drawing forward and pressing down the 
tongue, the margin of the false palate could be dis- 
tinctly seen, with its thick, swollen edge dipping down 
into the pharynx, and the uvula hanging in the center, 
pale-red and free from disease, or at most very slightly 
edematous. The tonsils were swollen, and agglutina- 
ted to the edges of the soft palate, and so matted with 
effusion of false membrane and fibrin as to be indis- 
tinguishable from the latter. 

" According to the testimony present, the disease 
was decidedly progressing ; there was more exudation, 
and the swelling was greater than six hours before. 
It was resolved to remove as much of the exudation as 
possible, no force being used, and to apply a strong 
solution of nitrate of silver, eighteen grains to the 
ounce. In four hours the breathing became noisy, 
not from implication of the larynx, but from blocking 
of the posterior nares, from increased swelling at the 
back part of the velum, and effusion of fibrinous 
secretion spotted with false membrane, and the corre- 
sponding difficulty of ingress of air by the mouth. 
Other measures, as inhalation and gargling, were 
adopted, and I may mention that the former always 
gave most relief. On the fourth day the report was, 



Drug Treatment. 207 

that the noisy breathing had considerably diminished ; 
the patient had slept two hours and a half ; at intervals 
of an hour, she had taken medicine, food, and wine, 
but with more difficulty than yesterday, and once the 
fluid returned by the nostrils ; the anterior part of the 
palate was less swollen, and the false membrane and 
fibrin secreted in much less quantity ; but the breath- 
ing was much more noisy than yesterday, and the 
cervical and submaxillary glands much more swollen ; 
general symptoms, pulse, etc., as before. It was felt 
that the caustic application had done good in one 
direction and mischief in another ; and the throat was 
mopped out, after removing gently all the exudation 
possible, with a solution of nitrate of silver ten grains 
to the ounce. 

" For some hours the breathing was less noisy, but 
the difficulty recurred. Next day the report was — no 
sleep, increased difficulty in swallowing, and consider- 
able accumulation about and behind the fauces ; injec- 
tion by the nares returned the same way ; occasional 
smothered cough ; the cervical, submaxillary, and 
neighboring glands immensely swollen. The mouth 
could not be opened wide enough to examine the 
throat. Laryngeal spasm occurred once, and was 
overcome by inhalation ; again in two hours, and 
overcome by the same means. Sonorous respiration 
followed, and in an hour a third spasm of the glottis 
ushered in the fatal event. 

" I know some persons may fail to see any connec- 
tion between the application of the caustic and the 
increased swelling and aggravation of symptoms ; and 
in this case it was contended by my consultant that 
the local treatment was the best possible under the 
circumstances, and that the fatal event would have 



208 DlPTHERIA. 

occurred as soon under any other mode of treatment. 
I confess to having thought so at the time, but in- 
creased experience has convinced me that any treat- 
ment which causes rapidly increasing swelling of the 
cervical, submaxillary, and neighboring glands is bad, 
and sure to be attended by corresponding extension of 
the disease within and below the fauces, by declension 
of power, and increase in the difficulty of breathing, 
swallowing, etc. And the reason is obvious enough. 
In fact, in all cases where the first application of 
caustic has shown the tendency to excessive glandular 
enlargements, the local treatment can not be too 
soothing and gentle. The treatment consisted of 
quinine in three-grain doses, with ether and muriatic 
acid, and given in rotation with strong beef-tea and 
wine, so that every hour the patient took medicine, 
food, or wine. 

" The treatment in which I have most faith, on or 
about the third day, under the circumstances above 
mentioned, is the following : Let as much of the exu- 
dation as is easily accessible and loose be removed. A 
carefully strained infusion of chamomiles is to be 
made, to which is added a few drops of creosote or of 
liquor calcis chlorinata (two drams to fifteen ounces), 
or liquor aluminis. It is to be used by means of Cox- 
etter's laryngeal syringe, or any other apparatus the 
practitioner may advise, so as to avoid the unrest of 
tissues created by gargling. The laryngeal syringe is 
admirably adapted for children, who, after a time, will 
use it themselves, although, of course, not very effect- 
ually. If there be much accumulation behind the 
velum, and discharge passes by the nares, it is an ex- 
ceedingly useful plan to syringe the throat through the 
anterior nares, with the same infusion. Most of the 



Drug Treatment. 209 

fluid comes back by the mouth, carrying with it debris 
of membrane and foul secretions. An effect at deglu- 
tition will almost always be made, but if some of the 
infusion be swallowed it can only do good. Inhala- 
tion from a hot infusion of the same has seemed to 
give more ease to the patient than any other applica- 
tion. "Washing out of the throat should not be insisted 
on more than three or four times a day — the inhalation 
as often as the patient may wish. The chlorinated 
lime, in addition, should be used if there be much 
fetor ; the alum when that is only slightly apparent. 
The throat outside should be surrounded by a poultice 
composed of the strained chamomile flowers, and 
changed four or five times in the twenty-four hours. 
Internally, I use quinine in chamomile infusion, with 
muriatic acid and ether, and endeavor to produce cin- 
chonism. I use chamomiles, having in view its 
reputed efficacy in erysipelas and phlegmonous inflam- 
mation. In one case only, where hematuria existed, 
I gave tincture of acetate of iron, with acetate of pot- 
ash in small quantity, and the patient did well." 

Dr. Richard Cammack, in the Lancet for Oct. 30, 
1858, gives us the following : 

" Treatment. — 1. A temperate, dry, well-ventilated 
room as can be obtained, no one being allowed to 
sleep in it except an attendant. Crowded bedrooms 
and animal effluvia are exciting causes. 

" 2. A calomel purgative, varying in strength ac- 
cording to the age and size of the patient ; and in chil- 
dren, where symptoms of laryngitis appear ; a rapid 
exhibition of the chloride of mercury, such as a grain 
to two grains every hour till the breathing is easier, 
and then every three or four hours, till the false mem- 
branes are loosened, the bowels evacuate green stools, 



210 DlPTHEEIA. 

or vomiting. Care is needed not to carry the mineral 
too far, but it can be borne in proportion to the strength 
of the patient and the sthenic form of the attack. Chil- 
dren who have been healthy, and are teething, have 
most inflammatory symptoms. 

" 3. The decoction of cinchona with hydrochloric 
acid, varying the dose of the latter from one minim to 
ten every four hours, in from a teaspoonful to two 
tablespoonfuls of the former. 

" 4. Gargle with chloride of sodium and vinegar, a 
tablespoonful of each in a teacupful of hot water ; also 
inject this up the nostrils when they are becoming ob- 
structed. This excels all other gargles ; it relieves 
the breathing and the fetor, and causes the ulcers to 
heal. 

"5. Apply the stick of nitrate of silver to every 
part where false membrane or exudation can be seen. 
By means of Dr. R. Quain's tongue depressor, one can 
see far and wide ; but when the patient will not sub- 
mit to this, and when the disease spreads beyond the 
reach of the caustic case, a probang and clean sponge 
well saturated with a strong solution of nitrate of sil- 
ver will answer. 

" 6. Rub the external fauces with compound iodine 
ointment night and morning ; and where erysipelas 
may appear, apply the stick, and lay on the plaster of 
strong mercury ointment. 

" 7. Keep the room and all else sweet and clean. 

" 8. A nutritious diet is necessary. A little mutton 
every day ; boiled milk, rich gruels, and beef- tea, with 
hot port-wine and water (half wine with sugar and 
lemon), for all above ten years ; and warm milk and 
water for minors. All things should be taken warm. 
Cold drinks are exciting causes. 



Drug Treatment. 211 

" The disease is not infectious, except, perhaps, under 
extraordinary circumstances. 

" Since I wrote the above remarks, I have seen many 
cases. I am convinced the malady is herpetic, and, 
therefore, would have called it so. It is malignant 
frequently, therefore herpes malignus anginosus would 
fully specify the disease. I have no wish to encroach 
on your space, but beg to observe that the medical 
gentlemen of this neighborhood are much at variance 
as to the nature of the disease, and that it has been 
very fatal. I have the Lancet from the commence- 
ment, and have read the lectures of most since Sir A. 
Cooper's and Mr. Abernethy's ; but I have never seen 
a full description of this epidemic." 

And next comes Dr. E. Peney, of Marden, Kent 
{Medical Times and Gazette^ March 5, 1859), with tur- 
pentine as the leading remedial agent. Dr. Peney 
remarks : 

" I have tried almost everything that I know to have 
been recommended, and have failed ; and, perhaps, we 
often shall fail under any treatment ; but I think it 
proper to mention a treatment which has been success- 
ful with me in three or four cases of late. It is for a 
child of from two to six years of age. Ten minims of 
the spiritus terebinthum every second hour, and five 
grains of the ammonise carbons every second hour, 
the child taking the turpentine one hour and the am- 
monise next hour. 

"I rub up 3ij. of the spiritus terebinthum with the 
yolk of an egg, and add enough syrup to make a jxij. 
mixture. One teaspoonful in milk every two hours. 
Then dissolve 3J. of the ammonise carbona3 in sxij. of 
water, and give one teaspoonful every two hours also 
in milk. 



212 DlPTHERIA. 

" Besides this the child takes port wine, porter, and 
beef-tea, or wine with the yolk of an egg ad lib. I 
have not found in any of my cases strangury caused 
by the turpentine. The patient dislikes it of course, 
and it requires a determined and attentive nurse ; but 
I have found the plan very successful, and I speak of 
those cases where decided croupy breathing and fits of 
suffocation have made their appearance. 

" I was induced to try the turpentine from having 
noted its effects, when given as advised by Mr. Carmi- 
chael in cases of iritis in broken-down constitutions 
where mercury could not be used, and where there is 
so great a tendency to the effusion of lymph in the 
chambers of the eye. We all know, too, how effectual 
it is in other diseases — acting like mercury in many 
respects — but stimulating instead of debilitating — and 
hence its appropriateness in diptheria, where mercury, 
I believe, hastens the fatal result. I now have recourse 
to no sponging the fauces with strong acid, or the ar- 
genti nitras, which I used to do, punishing a great deal 
and doing very little good." 

Dr. J. 0. S. Jennings, in the British Medical Jour- 
nal, July 16, 1859, describes a plan of treatment which 
he claims to have been successful, and which is, in all 
important particulars, so far as the drug remedies are 
concerned, in direct antagonism with the stimulating 
plan of Professor Clark and others. Indeed, its lead- 
ing agents are the most deadly antiphlogistics known 
to the materia medica. Dr. Jennings says : 

" The plan I have invariably adopted, regardless of 
sex, or age, or incubation of disease, has been to give 
an emetic of antimonial wine, from half an ounce to 
an ounce, according to age ; to freely cauterize the 
throat with solid nitrate of silver ; to have a mustard 



Drug Treatment. 213 

poultice applied from ear to ear ; the feet and legs 
plunged in a hot bath ; and the patient confined to 
bed. After the emetic action has ceased, from three to 
five grains of calomel with five of compound extract 
of colocynth were given (or, for a child twx) grains of 
calomel with two grains of compound antimonial pow- 
der), and, four hours after, a mixture of bisulphate of 
quinia, chlorate of potash, and diluted hydrochloric 
acid. A gargle of chlorine solution was directed to 
be used frequently. When the inflammatory stage 
has been severe, the fauces tense and shining, and the 
throat edematous, spirit of nitrous ether and liquor of 
acetate of ammonia, or nitrate of potassa, has been 
added to the mixture. 

" The diet has been at first farinaceous, and after- 
ward consisting of strong broths and jellies. Stimu- 
lants have been very rarely administered, and then 
only as sherry whey, alternately with the quinine, 
which I have trusted to as the sheet-anchor. For in- 
fants, quinine may be given in jelly, washed down 
w^ith a mixture of tincture of sesqui-chloride of iron. 
Too much stress can not be laid upon tartar emetic, 
quinine in large doses, and the avoidance or guarded 
use of alcoholic stimulants." 

The treatment recommended and practiced by Dr. 
Smith, of St. Mary Cray, Kent {British Medical Jour- 
rial) July 16, 1859), is essentially the opposite of that 
of Dr. Jennings; and as his experience and observa- 
tions are, on several points, in direct conflict with those 
of several authors we have just quoted, I give his re- 
marks in full : 

" The principles that have guided my treatment of 
this disease are : first, to arrest the local inflammation 
by exciting another of a different character ; second, to 



214 , DlPTHERIA. 

employ elimination according to the individual case ; 
third, in all cases to sustain vigorously the vital 
powers. 

" To accomplish the first indication, I prefer the em- 
ployment of a strong solution of the nitrate of silver. 
Having first cleared the fauces, etc., as far as practica- 
ble by gentle means, I paint every affected part, and 
beyond it, with the solution, of the strength of fifteen 
grains to a dram. In mild cases I have frequently 
tried one of milder strength, say five grains ; but I am 
satisfied that in all cases an efficient application of the 
full strength is the best. It is perfectly safe, and has 
at once a marked effect. It is more efficiently applied 
by a full-sized camel-hair pencil than a sponge. Se- 
vere cases must be seen again in twelve hours, and the 
application repeated should the so-called membrane 
spread. Later in the treatment, a weaker solution 
may be used, or Bretonneau's application, one part of 
hydrochloric acid to three of honey. And later still, 
when the membrane has disappeared, but much full- 
ness and puffiness of the parts continue, a gargle, con- 
taining the sesqui-chloride of iron, or tannic acid. 
"Where, as in my second case, there is much fetor, the 
chlorate of potassa is applicable. And where, as in my 
third case, there is more tonsillitis, we may, with ad- 
vantage, employ inhalation of steam, or warm milk 
gargle. After the membrane is removed, and the ten- 
dency to diptheritic deposit supposed to be arrested, 
the throat must be carefully watched ; for until the en- 
demic condition of the system is conquered, we may 
have a relapse of diptheria. 

" I commence the treatment of almost every case 
with a purge, varying with the state of the tongue, 
pulse, etc. ; but by far the most frequently, calomel 



Drug Treatment. 215 

and rhubarb, carefully avoiding salines. In some 
cases, with loaded tongue and suffused countenances, 
I have given, with the greatest advantage, emetics. 
Indeed, I am now so satisfied of their value, that I 
shall for the future employ them more frequently, es- 
pecially where the congestion is marked, or there is 
unusual tonsillitis. The further general treatment is 
of great importance, namely, that directed to sustain 
the vital powers and remove anaemia. 

" I need not dwell upon the necessity of wine, beef- 
tea, etc. In the severe cases these are most urgently 
required, and must be liberally supplied. In the more 
trifling cases, if well marked, convalescence will be 
delayed, and danger of relapse continue, if these, or 
their equivalents, are not employed. 

" Of all the medicines that may present themselves 
for our choice, there is one far superior, in my experi- 
ence, to all others ; and upon which I, indeed, chiefly 
rely : tincture of sesqui-chloride of iron. I have tried 
others that were obvious ; but none sustain the vital 
powers, steady the pulse, lessen its frequency, and give 
potency to it ; none remove the soft clam of the skin, 
steady the action of the kidney, and remove the anae- 
mic pallor of the face, as does this. My confidence in 
its employment, and also in the use of the nitrate of sil- 
ver, is fortified by their effects in erysipelas, in which 
they are almost specific. Cases will occur in which 
this treatment must be deferred, or modified, as where 
the tonsillitis is severe. In those cases, with the appro- 
priate local treatment, I have first used the decoction 
of cinchona, with liquor of acetate of ammonia, or the 
latter with ammonia ; but we afterward come to the 
steel. 

" Such is a brief outline, and time admits of no 



216 DlPTHERIA. 

more, of the treatment of cases in which croup has 
not intervened. How are we to meet this formidable 
extension of the disease ? Shall we, in any cases, re- 
sort to tracheotomy ? I think not. Success, in re- 
ported cases, has not justified it; and we can not tell 
how far the membranous deposit has extended. I 
have had urgent cases of this description, and, happily, 
have hitherto treated them with success. My sheet- 
anchor is emetics, repeated, and very active ones, al- 
ways of ipecacuanha and sulphate of zinc, never of an- 
timony. 

" Did time admit, I would detail these cases, but 
they present no peculiarity except the urgency of the 
symptoms. In one child, three years of age, I gave 
seven emetics before the symptoms were fully relieved. 
Portions of the membrane were detached and thrown 
oif in the act of vomiting. I gave wine and ammonia 
in the intervals. In this case I gave also repeated 
small doses of calomel, because Bretonneau recom- 
mends it : and the case being of extreme urgency, I 
would not neglect one of such authority. 

" In the more severe cases of diptheria, I can not 
too impressively recommend strict horizontal position. 
I have seen more than one case in which fatal syncope 
was to be apprehended if this had been neglected." 

But a truce with druggery. We have had enough 
of it. We have been surfeited with the contradic- 
tory stories of their virtues and their bad effects, and 
with the absurd reasonings and conflicting state- 
ments of their advocates and authors. And I conclude 
this chapter of inconsistencies with an article written 
more than a century ago, and published in Boston in 
1740. The discriminating reader will readily perceive 
that, however much physicians have progressed in the 



Drug Treatment. 217 

grammar school, they have, so far as the treatment of 
malignant diseases is concerned, " advanced backward" 
since the following article was published. It was 
written to a friend by a clergyman, in reference to 
what has since been called, " The Throat-Distemper 
of the Last Century," and which is supposed by many 
to be identical with the now prevalent diptheria. 

" Sir — In Compliance with your Desire, I shall now 
communicate to you some of those Observations I have 
made upon that extraordinary Disease, which has 
made such awful Desolations in the Country, com- 
monly called the Throat-Distemper. 

" This Distemper first began in these Parts, in Febr. 
1Y34:,5. The long continuance and universal Spread 
of it among us, has given me abundant Opportunity 
to be acquainted with it in all its Forms. 

" The first Assault was in a Family about ten Miles 
from me, which proved fatal to eight of the Children 
in about a Fortnight. Being called to visit the dis- 
tressed Family, I found upon my arrival there, one of 
the Children newly dead, which gave me the Advan- 
tage of a Dissection, and thereby a better Acquaint- 
ance with the Nature of the Disease, than I could 
otherwise have had : From which (and other like) 
Observations, I came pretty early into the Methods of 
Cure that I have not yet seen Reason to change. 

" There have few Distempers been ever known, that 
have put on a greater variety of Types, and appeared 
with more different Symptoms, than this has done ; 
which makes it necessary to be something particular 
in describing it, in order to set it in a just View, and 
to propose the Methods of Cure necessary in its several 
Appearances. And 

" 1. I take this Disease to be naturally an Eruptive 
10 



218 DlPTHEKIA. 

niilliaiy Fever : and when it appears as such, it 
usually begins with a Shivering, a Chill, or with 
Stretching, or Yawning ; which is quickly succeeded 
with a sore Throat, a Tumefaction of the Tonsils, Uvula 
and Epiglottis, and sometimes of the Jaws, and even 
of the whole Throat & Neck. The Fever is often acute, 
the Pulse quick & high, and the Countenance florid. 
The Tonsils first, and in a little Time the whole Throat 
covered with a whitish Crustula, the Tongue furr'd, 
and the Breath fetid. Upon the 2d, 3d, or 4th Day, 
if proper Methods are used, the Patient is covered with 
a milliary Eruption, in some exactly resembling the 
Measles, in others more like the Scarlet Fever (for 
which Distemper it has frequently been mistaken) but 
in others it very much resembles the confluent Small 
Pox. When the Eruption is finished, the Tumefaction 
everywhere subsides, the Fever abates, and the Slough 
in the Throat casts off and falls. The Eruption often 
disappears about the 6th or 7th Day ; tho' it sometimes 
continues visible much longer. After the Eruption is 
over, the Cuticle scales and falls off, as in the Con- 
clusion of Scarlet Fever. If after the Crise of this 
Disease Purging be neglected, the Sick may seem to 
recover Health and Strength for a while ; yet they 
frequently in a little Time fall again into grievous 
Disorders ; such as a great prostration of Strength, loss 
of Appetite, hectical Appearances, sometimes great 
Dimness of Sight, and often such a weakness in the 
Joints as deprives them of the Use of all their Limbs ; 
and some of them are affected with scorbutick Symp- 
toms of almost every Kind. 

" When this Distemper appears in the Form now 
described, it is not very dangerous : I have seldom 
seen any die with it, unless by a sudden Looseness, 



Drug Treatment. 219 

that calls in the Eruptions ; or by some very irregular 
Treatment. But there are several other very different 
Appearances of the Disease, which are attended with 
more frightful & deadly consequences. 

" 2. It frequently begins with a slight Indisposition, 
much resembling an ordinary Cold, with a listless 
habit, a slow & scarce discernible Fever, some sore- 
ness of the Throat and Tumefaction of the Tonsils ; 
and perhaps a running of the Nose, the countenance 
pale, and the Eyes dull and heavy. The patient is not 
confin'd, nor any Danger apprehended for some Days, 
till the Fever gradually increases, the whole throat, 
and sometimes the Roof of the Mouth and Nostrils, are 
covered with a cankerous Crust, which corrodes the 
contiguous Parts, and frequently terminates in a mortal 
Gangreen, if not by seasonable Applications pre- 
vented. The Stomach is sometimes, and the Lungs 
often, covered with the same Crustula. The former 
Case is discovered by a vehement Sickness of the 
Stomach, a perpetual vomiting ; and sometimes by 
ejecting of black or rusty and fetid Matter, having 
Scales like Bran mixed with it, which is a certain 
Index of a fatal Mortification. — When the Lungs are 
thus affected, the Patient is first afflicted with a dry 
hollow Cough, which is quickly succeeded with an 
extraordinary Hoarseness and total Loss of the Yoice, 
with the most distressing asthmatic Symptoms and 
difficulty of Breathing, under which the poor miserable 
Creature struggles, until released by a perfect Suffoca- 
tion, or stoppage of Breath. — This last has been the 
fatal Symptom, under which the most have sunk, that 
have died in these Parts. And indeed there have 
comparatively but few recovered, whose Lungs have 
been thus affected. All that I have seen to get over 



220 DlPTHERIA. 

tliis dreadful Symptom, have fallen into a Ptyalism or 
Salivation, equal to a petit Flux de Bouclie, and have 
by their perpetual Cough expectorated incredible 
Quantities of a tough whitish Slough from their Lungs, 
for a considerable Time together. And on the other 
Hand, I have seen large Pieces of this Crust, several 
Inches long and near an Inch broad, torn from the 
Lungs by the vehemence of the Cough, without any 
Signs of Digestion, or possibility of obtaining it. 

u Before I dismiss this Head, I must observe that 
the Fever which introduces the terrible Symptoms 
now described, does not always make such a slow and 
gradual Approach : but sometimes makes a fiercer 
Attack ; and might probably be thrown off by the 
Eruptions, and this Train of Terrors prevented, if 
proper Methods were seasonably used. 

" 3. This Distemper sometimes appears in the Form 
of an Erysipelas. The Face suddenly inflames and 
swells, the Skin appears of a darkish Red, the Eyes 
are closed with the Tumefaction, which also sometimes 
extends through the whole Neck and Chest. Blisters 
or other small Ulcers here and there break out upon 
the Tumor, which corrode the adjacent Parts ; and 
quickly bring on a Mortification, if not by some happy 
Means prevented. Some that are thus affected, are at 
the same time exercised with all the terrible internal 
Symptoms above described ; and some with none of 
them. If this inflamed Tumor be not quickly dis- 
cussed, it will (I think) always prove mortal. 

" 4. Another Appearance of this Disease is in ex- 
ternal Ulcers ; which break out frequently behind the 
Ears ; sometimes they cover the whole Head and 
Forehead ; sometimes they appear in the Arm-Pits, 
Groins, Navil, Buttocks or Seat ; and sometimes in any 



Drug Treatment. 221 

of the extream Parts. These are covered with the 
same Kind of whitish Crustula above described, which 
also corrodes the contiguous Parts ; and quickly, if 
not prevented, ends in a Mortification. I have ordi- 
narily observed, that if these outward Ulcers are 
speedily cured, the Throat and internal Parts remain 
free from the above mentioned terrible Symptoms ; 
otherwise the miserable Patient must pass thro' the 
whole tragical Scene of Terrors before represented, if 
an external Gangreen don't terminate his Agony and 
Life together. 

" 5. Sometimes this Disease appears first in Bubo's 
under the Ears, Jaws, or Chin, or in the Arm-Pits, or 
Groin. These, if quickly ripened, make a consider- 
able Discharge ; which brings a salutary end to the 
Disease ; otherwise they quickly end in a fatal Mortifi- 
cation ; or else bring on the whole foremention'd 
Tragedy. 

" 6. This disease appears sometimes in the Form of 
a Quinsey. The Lungs are inflamed, the Throat and 
especially the Epiglottis exceedingly tumefied. In a 
few Hours the Sick is brought to the Height of an Or- 
thopncea ; and can not breathe but in an eract Pos- 
ture, and then with great Difficulty and Noise. This 
may be distinguished from an Angina, by the Crustula 
in the Throat, which determines it to be a Sprout from 
the same Root with the Symptoms described above. 
In this Case the Patient sometimes dies in twenty-four 
Hours. I have not seen any one survive the third 
Day. But thro' the divine Goodness these symptoms 
have been more rarely seen among us, and there have 
been but few in this Manner snatched out of the 
world. 

" As the Symptoms of this Distemper are very dif- 



222 DlPTHERIA. 

ferent, so the Methods of Cure should be respectively 
accommodated to them ; and I shall therefore consider 
them distinctly. 

" When this Distemper makes its Attack with the 
Symptoms of a high Fever, a florid Countenance &c. 
(as in the first Case described) the first Intention, to be 
pursued towards a Cure, is to bring out the Eruptions 
as soon as possible ; to which End, I order the Patient 
to be confin'd in Bed, and put into a gentle breathing 
Sweat, till they appear. A Tea made with Virginian 
Snake-Root and English Saffron, with a few Grains of 
Cochineal ; A Posset made with Carduus Marise boil'd 
in Milk, and turn'd with Wine, the Lapis contrayerva, 
or Gascoign-Powder ; any or all of these, as occasions 
require, answer to this Purpose, and seldom fail of 
Success. 

" One of the most dangerous Circumstances that at- 
tend this Disease, is a Looseness, that frequently hap- 
pens upon the first Appearance of the Eruptions ; 
which must be speedily restrain'd, and the Belly kept 
bound, lest the morbifick Matter evaporated by the 
Pores, be recalled into the Blood, and prove suddenly 
fatal. — To that Purpose, I ordinarily advise to Venice- 
Treacle, or liquid Laudanum, which commonly answer 
all intentions. But if the Patient should be in a doz- 
ing Habit, that these cannot be used, or if these should 
fail of Success, any other Astringent may be used that 
is proper in a Diarrhoea. 

"The Ulcers in the Throat should be constantly 
cleansed, from the Time of their first Appearance. I 
have found the following Method most successful to 
this Purpose. Take Roman Vitriol, let it lie as near 
the fire as a Man can bear his Hand, till it be thor- 
oughly calcined and turn'd white : Put about eight 



Drug Treatment. 223 

Grains of this into half a Pint of Water ; Lay down 
the Tongue with a Spatula ; and gently wash off as 
much of the Crust as will easily separate, with a fine 
Eagg fastened to the End of a Probe or Stick, and wet 
in this liquor made warm. This Operation should be 
repeated every three or four Hours. 

" After the Eruptions are quite gone, the Patient 
should be purged two or three Times, to prevent the 
Consequences above described ; and this Pule should 
be observed in every Form of the Disease. 

" If after the Crise of this Disease, in any of its Ap- 
pearances, the Sick should fall into any of the Disor- 
ders mentioned under the first Head, such as Loss of 
Strength, a feverish Habit, Dimness of Sight, Weak- 
ness of the Joynts &c, Repeated Purging, as far as 
the Patient's Strength will bear, with Elixir Proprieta- 
tis, given twice a Day in a glass of generous Wine, 
will constantly remove these Difficulties. 

" When this Disease makes a more slow and leis- 
urely approach with a lingering Fever, pale Counten- 
ance &c. as described in the second Case, all Attempts 
to bring out the milliary Eruptions seem in vain. And 
therefore, tho' the Sick may be very much relieved by 
the diaphoretick Medicines abovementioned, if repeat- 
edly used during the Course of the Illness ; yet these 
are not to be depended upon for a Cure. But a brisk 
Purge should be also directed every third Day, and 
those Cathartics that are mixt with Calomel or Mer- 
curius dulcis, are most likely to be serviceable, 
where the Age and Strength of the Patient will 
bear it. 

" If there be an extream nauseating, and vehement 
Sickness of the Stomach, that can't be otherwise 
quieted, an Emetick seems necessary, tho' I have not 



224 DlPTHEEIA. 

found Encouragement to use vomiting Physick in any 
other Case. 

" The internal Ulcers of the Throat should be treated 
as above directed ; but if there be a great Tumefac- 
tion of the Glands, I order externally a Plaister of 
Diachylon cum Gummi and de Ranis cum Mercurio 
mixt ; and internally the following Fumigation. Take 
"Wormwood, Penny-royal, the Tops of St. John's Wort, 
Camomile-Flowers and Elder-Flowers, of each equal 
parts ; boil very strong in Water ; when boil'd, add as 
much Brandy or Rum as of this decoction ; steam the 
Throat, thro' a Tunnel, as hot as can be born, three or 
four Times a Daj^. 

" When the Lungs are seized with this cankerous 
Crustula, which is indicated by the Cough and Hoarse- 
ness above described, Mercurial Catkarticks frequently 
repeated seem the best of any Thing to promote Ex- 
pectoration. I have also found Success in the Use of 
the Syrup of red Poppies and Sperma Ceti mixt. 

" When this Distemper appears in the Form of an 
Erysipelas, I have used the following Fomentation 
with good Success. Take Wormwood, Mint, Elder- 
Flowers, Camomile-Flowers, the Tops of St. John's 
Wort, Fennel-Seeds pounded, and the lesser Centaury, 
equal Parts ; Infuse in good Brandy or Jamaica Rum, 
in a Stone-Jugg well stop'd, and keep hot by the Fire : 
wet a Flannel Cloth with this ; and after moderately 
squeezing out the Liquor, apply three or four double 
to the Tumor, as hot as can be born, every Hour. — In 
this Case I repeat Purging, as above directed. 

" As for the external Ulcers above described (under 
the 4th Head) they may be always safely and speedily 
cured, by applying once or twice a Day a good thick 
Pledget of fine Tow dipt in the above described vit- 



Dkug Treatment. 225 

riolick water. I have never known this fail in a single 
Instance, when seasonably used. But then it must be 
observed, that some of these Ulcers will require this 
Water much sharper with the Vitriol, than others will 
bear. It should be so sharp as to bring off the Slough, 
dry up the flow of corrosive Humors, and promote a 
Digestion : but it must not be made a painful Caus- 
tick. In this the Practitioner's Discretion will guide 
him. 

u I need not say any more respecting the Bubo's, 
mentioned under the fifth Head : but that they must 
by all possible Means be ripen'd as quick as they can ; 
and launced as soon as they are digested and found to 
contain any Pus. 

" I have not yet found any effectual Remedy in the 
6th and last Case described. 

" Upon the Disease in general, I have made the fol- 
lowing Remarks ; which perhaps may be of some Use. 

" I have observ'd, that the more acute the Fever is 
on the first Seizure, the less dangerous ; because there's 
more Hope of bringing out the Eruptions. 

" I have observ'd, that there's more «Danger of re- 
ceiving Injury from a cold Air in this, than in any 
eruptive Fever I have seen. The Eruptions are easily 
struck in ; and therefore there ought to be all possible 
Care, that the Sick be not at all exposed to the Air, 
till the Eruptions are quite over and gone. 

" I have also observ'd, that there's much greater 
Danger from this disease in cold Weather, than in hot. 
In cold Weather it most commonly appears in the 
Form described under the second Head ; while on the 
contrary, a hot Season very much forwards the Erup- 
tions. 

" I have frequently observ'd, that once having this 
10* 



226 DlPTHERIA. 

Disease is no Security against a second Attack. I have 
known the same person to have it four Times in one 
Year ; the last of which prov'd mortal. I have known 
Numbers, that have passed thro' it in the eruptive 
Form in the Summer Season, that have died with it 
the succeeding Fall or Winter : tho' I have never seen 
any upon whom the Eruptions could be brought out 
more than once. 

" I have ordinarily observ'd, that those who die 
with this Disease, have many Purple-Spots about 
them ; which shews the Height of Malignity and Pes- 
tilential Quality in this terrible Distemper. 

" Thus, Sir, I have endeavor'd in the most plain and 
familiar Manner to answer your Demands. I have not 
attempted a Philosophical Inquiry into the Nature of 
this Disease, nor a Rationale upon the Methods of 
Cure. I have meant no more than briefly to commu- 
nicate to you some of my Experiences in this Distem.- 
per, which I presume is all you expect from me. If 
this proves of any Service, I shall have Cause of Thank- 
fulness : If not, you'll kindly accept my willingness to 
serve you, and to contribute what I can towards the 
Relief of the afflicted and miserable. I am Sir, 
" Your most humble Servant, 

" Jonathan Dickinson. 

"Elizabethtown, N. Jersey, Febr. 20, 1738,9. 
" POSTSCRIPT. 

" Since I wrote this Letter, I am inform'd by a Gen- 
tleman of the Profession, who has had very great Im- 
provement in this Distemper, That he has found out a 
Method of Cure, which seldom fails of Success in all 
the Forms of this Disease herein described, (the first, 
fourth, and fifth only excepted, which should be treated 
as above directed) and that is a Decoction of the Root 



Hygienic Treatment. 227 

of the Dart Weed, or (as it is here called) the Squaw 
Root. He orders about an Ounce of this Root to be 
boiled in a Quart of Water, to which he adds when 
strain'd a Jill of Rum and two Ounces of Loaf-Sugar ; 
and boils again to the consumption of one quarter 
Part. This he gives his Patients frequently to drink, 
and with this orders them frequently to gargle their 
Throats ; allowing no internal Medicine but this only, 
during the whole Course of the Disease, excepting a 
Purge or two in the Conclusion. I have seen a sur- 
prising Effect of this Method in one Instance ; and 
shall make what further Observations I can : And if 
this answ r ers my present Hopes, I shall endeavor to 
give you further Information. 

" The Dart- Weed grows with a strait stalk six or 
eight Foot high, is jointed every eight or ten Inches 
apart ; and bears a large white Tassell on the Top, 
when in the Flower. The Root is black and bitterish." 

HYGIENIC TREATMENT OF DIPTHERIA. 

Having seen what merit there is in the drug treat- 
ment of diptheria, and what reliance can be placed on 
the theories and experience of medical men, who be- 
lieve in a system which is in opposition to Nature, 
contrary to common sense, and in direct antagonism 
with every law of the vital organism, let us now pro- 
ceed to consider the rational treatment of the disease. 

As I have already explained, diptheria consists 
essentially of a local inflammation and a general fever. 
In many cases the throat affection, which is the local 
inflammation, is slight, while the constitutional affec- 
tion, or general fever, is severe ; and in other cases the 
reverse happens — the local affection being severe and 



228 DlPTHERIA. 

the fever slight. The fever is always of the low, 
atonic, and typhoid character. The local inflammation, 
in all severe cases, is attended with an excretion of 
coagulable lymph, which, concreting into a false mem- 
brane, forms a preternatural crust or coating to the 
mucous surface, to be cast off, like all other foreign 
or abnormal substances. When spread over a large 
portion of the larynx, trachea, or bronchial ramifica- 
tions, this membranous concretion may occasion death 
by suffocation. In the other cases which terminate 
fatally, death is the result of exhaustion. 

The cause of diptheria is poison, virus, or impurities 
of some kind in the blood. The disease itself is an 
effort of the system to purify itself by expelling these 
impurities. When the remedial effort is chiefly di- 
rected to the surface, there will be much constitutional 
disturbance of the kind denominated fever. If the 
determination to the surface is attended with consider- 
able heat and dryness of the skin, it may be mistaken 
for high or sthenic fever. When the process of purifi- 
cation is determined chiefly to the mucous membrane, 
there will be corresponding disturbance of the function 
of the part, and of the character which medical authors 
recognize as inflammation. When the whole mass of 
blood is very gross, and the determination to the 
throat very violent, ulceration and disorganization of 
the structure follow rapidly, and the disease takes the 
name of " putrid sore throat." In many cases the 
process of depuration is very nearly equally divided 
between the skin and mucous membrane, in wdiich 
case the life of the patient usually depends on the 
kind of medication — whether it increases the determin- 
ation to or from the external surface. Medicines may 
be employed which do not materially unbalance nor 



Hygienic Treatment. 229 

derange the existing remedial effort, and although 
they are really a damage to the patient, and prolong 
the convalescence, yet because they are not apprecia- 
bly mischievous at the moment, they may get the 
credit of curing the disease. 

When the remedial struggle is nearly balanced, or 
directed chiefly to the external surface, there is very 
little danger, and such cases seldom terminate fatally, 
except as death is the result of maltreatment. The 
danger results from the concentration of morbid action 
to a particular point, thus disorganizing and destroying 
the tissue ; hence the danger may be measured, as a 
general rule, by the violence of the throat-affection. 
There are cases, however, in which the system is so 
gross, the blood so impure, and all the fluids so foul, 
that before the remedial effort has become established 
in the direction of any outlet, the patient will sink and 
die of exhaustion, with very slight manifestations of 
general fever or of local inflammation. 

When the patient is blessed with a good constitu- 
tion, and his habits of living and exposure to infection 
are not such as to render his blood and secretions 
greatly depraved, the remedial effort — the process of 
purification — will be so equally balanced and so well 
maintained, that he will bear a great amount of inju- 
rious treatment, and endure a hundred doses of drug 
poisons, without losing his life. But if, on the con- 
trary, the constitution is very frail or very gross, so 
that the morbid action is directed wholly from the 
surface, a small bleeding, a single leech, a blister, a 
cathartic dose, a mercurial purge, or an antimonial 
emetic, or a single touch of the burning caustic, may 
decide the case against the patient in a few hours. 

The danger of diptheria results, usually, from the 



230 DlPTHERIA. 

excessive determination of morbid action to the throat ; 
and, hence, the obvious indication of cure is to coun- 
teract this determination by promoting depuration, in 
other directions, especially through the skin. By 
counteracting this determination of morbid action, or 
of remedial effort — for, however strange the language 
may seem to persons unaccustomed to it, these phrases 
really mean the same thing — I do not mean repressing 
or subduing it, but regulating it. 

And here is the great principle which underlies all 
correct medication, and which forms the broad dis- 
tinction between Hygienic and Drug Treatment. I 
do not look upon disease as a thing to be " subdued," 
" suppressed," " destroyed," " expelled," or extermin- 
ated. It is an action to be regulated. To regulate 
remedial effort, or morbid action, is simply so to con- 
trol and direct it that each organ or part may perform 
its own appropriate duty, to the end that no structure 
may be disorganized by having too great a burden 
thrown upon it. Instead of subduing disease by 
merely opposing or counteracting the symptoms, the 
proper business of the physician is so to diffuse, direct, 
and equalize it, that it may successfully accomplish its 
work of purification. 

The first indication, then, in the treatment of dip- 
theria, is to balance the circulation, and in fulfilling 
this indication the temperature of the body is the prop- 
er and the infallible guide. Wherever there is de- 
ficient circulation there are coldness and paleness, and 
wherever there is congestion or obstruction there are 
pain, heat, and disturbed function ; and these condi- 
tions must ever be kept in mind, as they are the basis 
of all proper therapeutic applications and processes. 

We have seen that the disease may be attended with 



Hygienic Treatment. 231 

all grades and shades of typhoid fever, and with all de- 
grees of atonic local inflammation. The constitutional 
disturbance which we denominate fever, may be at- 
tended with much or little preternatural heat of the 
surface, or with none at all ; or with a temperature be- 
low the normal standard ; or with irregular tempera- 
ture — some parts of the surface being above and others 
below the normal standard. 

The general remedial plan, therefore, so far as the 
fever is concerned, is resolved into the simple idea of 
regulating the temperature. To do this is to promote 
equal distribution of the blood, in other words, to 
balance the circulation ; and as functional action is 
always in proportion to the vigor of the circulation, so 
by regulating the temperature and balancing the cir- 
culation, we supply the conditions which enable " Na- 
ture" to cure the disease ; or, in less figurative phrase- 
ology, which aid and assist the living system to do its 
work of purification. 

The cure of disease consists in removing the causes ; 
not in silencing the remedial struggle / for this is but 
killing the patient. 

If these views are correct — and no medical man will 
ever seriously controvert them — it is easy to under- 
stand how it is, and why it is, that a bleeding, or a 
blister, or a dose of Epsom salts, or an antiphlogistic 
operation of niter, antimony, colchicum, digitalis, ac- 
onite, or veratria may quickly extinguish the patient's 
lamp of life, by concentrating remedial action in the 
center of the vital domain, when all of the living en- 
ergies are needed to determine the morbid matter to 
the surface. 

They show, too, the great delusion of the medical 
profession, in relying on stimulants or antiphlogistic^ 



232 DlPTHERlA. 

to promote action to or from the surface. All that 
these agents do, or can do, is to occasion or aggravate 
a fever, or induce or aggravate a local inflammation, 
thus adding to the causes of disease, and necessitating 
a waste of vital power to get rid of them. 

Nature does not own, and the living system abhors 
this whole plan — though it be the plan of the whole 
medical profession — of " curing a primary disease by 
creating a drug disease." 

To balance the circulation, regulate the temperature, 
promote external depuration, and remove congestion 
and obstruction, we do not need the inflaming stimu- 
lants, the corroding caustics, the paralyzing narcotics, 
nor the deadly antiphlogistics. We have in water 
alone all that is usable or useful for the purpose indi- 
cated. It may be employed of any temperature from 
ice to steam, according to the circumstances of any 
given case. Water is the sole vehicle by means of 
which all of the nutrient materials of the body are 
transported to the various structures, by which all of 
the effete materials or waste matters of the body are 
carried to the various outlets, and is also the material 
by which the temperature of the system is properly 
radiated, balanced, maintained, and regulated. There 
is nothing provided in the universe that can subserve 
these purposes except water. And if it plays so im- 
portant a part in the normal exercise of the functions, 
it becomes even more necessary, if possible, in their 
abnormal exercise — the state of disease — when there is 
extra and unusual duty to perform. 

In the state of health, and under all the ordinary 
circumstances of life, the temperature of the body is 
easily regulated, and the circulation balanced, so that 
disease is prevented, by means of air, exercise, cloth- 



Hygienic Treatment. 233 

ing, and artificial heat. In health the external rise of 
water is often refreshing and invigorating, and condu- 
cive to longevity; but in disease it becomes a necessity. 
In disease there are venoms, viruses, poisons, or accu- 
mulated impurities of some kind, to be diluted and 
washed away ; and this calls for a more free use of 
water internally than is demanded in the state of 
health. And as the solvent and detergent properties 
of water are in the direct ratio of its purity, how ab- 
surd is the practice of medicating the water — whether 
it is to be employed externally to regulate tempera- 
ture, or internally to cleanse the system of noxious 
matters — with mustard, vinegar, saleratus, salt, ashes, 
spirits, roots, herbs, barks, leaves, flowers, seeds ! etc. 
Although these foreign substances do not in all cases 
prevent the water from having some degree of benefi- 
cial effect, they always diminish its value in proportion 
to their quantity. There would be just as much sense, 
reason, or science in taking the impure water of the 
ocean to cook victuals or wash clothes with, as to em- 
ploy water holding in solution mineral, earthy, or al- 
kaline ingredients to cleanse the solids and purify the 
fluids of the living system. 

It is true that there are persons who call themselves 
" Hydropathic" physicians, and who are the proprie- 
tors of what they advertise as " Water-Cure" estab- 
lishments, who recommend and prescribe " mineral 
waters ;" but I could never understand why the 
poisons or impurities taken from " medicinal springs" 
are so different from the same poisons or impurities 
obtained at the apothecary shop. 

Before proceeding to explain the proper treatment for 
diptheria, I will, in order to save repetition, copy from 
a small work I have published — " Water-Cure for the 



234 DlPTHERTA. 

Million, 55 a description of the various bathing processes, 
so far as they may be applicable to home-treatment : 

" 1. Wet-Sheet Packing. — On a bed or mattress 
two or three comfortables or bed-quilts are spread ; 
over them a pair of flannel blankets ; and lastly, a wet 
sheet (rather coarse linen is best) wrung out lightly. 
The patient, undressed, lies down flat on the back, and 
is quickly enveloped in the sheet, blanket, and other 
bedding. The head must be w^ell raised with pillows, 
and care must be taken to have the feet well wrapped. 
If the feet do not warm with the rest of the body, a 
jug of hot water should be applied ; and if there is 
tendency to headache, several folds of a cold wet cloth 
should be laid over the forehead. The usual time for 
remaining in the pack is from forty to sixty minutes. 
It may be followed by the plunge, half-bath, rubbing 
wet sheet, or towel-wash, according to circumstances. 
The pack is not intended as a sweating process, as 
many suppose, though a moderate perspiration is not 
objectionable. A comfortable temperature of the sur- 
face is the desideratum, independent of more or less 
sweating, or none at all. "When the patient warms up 
rapidly, thirty minutes or less will be long enough to 
remain enveloped ; but when he becomes warm slowly 
and with difficulty, an hour, or more, is not too long. 
In some cases it is necessary to put hot bottles to the 
sides as well as to the feet. When the object is to cool 
a fever, the sheet should be allowed to retain more 
water, or if the skin is very hot, double sheets may be 
used. In chronic diseases, when the main object is to 
induce ' reaction, 5 or rather circulation, toward the 
surface, the sheet should be wrung more thoroughly, 
and the patient enveloped with a greater quantity of 
blankets, comfortables, or other bedding. 



Hygienic Treatment. 235 

" 2. Hale-Pack. — This is the same as the preceding, 
with the exception that the neck and extremities are 
not covered by the wet sheet, which is applied merely 
to the trunk of the body, from the armpits to the hips. 
It is adapted to those whose circulation is too feeble 
for a full pack ; it is also often employed as a prepara- 
tion for the full pack. 

" 3. Half-Bath.— An oval or oblong tub is most 
convenient, though any vessel allowing a patient to sit 
down with the legs extended will answer. The water 
should cover the lower extremities and about half of 
the abdomen. "While in the bath, the patient, if able, 
should rub the lower extremities, while the attendant 
rubs the chest, back, and abdomen. 

" 4. Hip or Sitz-Bath. — Any small-sized wash-tub 
will do for this, although tubs constructed with a 
straight back, and raised four or five inches from the 
floor, are much the most agreeable. The water should 
just cover the hips and lower part of the abdomen. 
A blanket should be thrown over the patient, who will 
find it also useful to rub or knead the abdomen with 
the hand or fingers during the bath. 

" 5. Foot-Bath. — Any small vessel, as a pail, will 
answer. Usually the water should be about ankle- 
deep ; but very delicate invalids, or extremely suscep- 
tible persons should not have the water more than 
half an inch to one inch in depth. During the bath, 
the feet should be kept in gentle motion. Walking 
foot-baths are excellent in warm weather, where a cool 
stream can be found. 

" 6. Wet and Cold Foot-Bath. — Place the feet in 
water as warm as can be borne for five to ten minutes ; 
then dip them for a moment in cold water, and wipe 
dry. 



236 DlPTHERIA. 

" 7. Rubbing Wet-Sheet. — If the sheet is used drip 
pingly wet, the patient stands in the tub ; if wrung so 
as not to drip, it may be used on a carpet or in any 
place. The sheet is thrown around the body, which it 
completely envelops below the neck ; the attendant 
rubs the body over the sheet (not with it), the patient 
exercising himself at the same time by rubbing in front. 

" 8. Pail-Douche. — This means simply pouring 
water over the chest and shoulders from a pail. 

" 9. Stream-Douche. — A stream of water may be 
applied to the part or parts affected, by pouring from 
a pitcher or other convenient vessel, held as high as 
possible ; or a barrel or keg may be elevated for the 
purpose, having a tub of any desired size. The power 
will be proportional to the amount of water in the 
reservoir. 

" 10. Towel or Sponge Bath. — Rubbing the whole 
surface with a coarse wet towel or sponge, followed by 
a dry sheet or towels, constitutes this process. 

" 11. Affusion Bath. — This implies pouring water 
gently over the surface of the body. The patient may 
stand in a tub, or lie on the bed, the bedding being 
protected by a sheet of India-rubber or gutta-percha. 

" 12. The Plunge-Bath. — This is employed but 
little, except at the establishments. Those who have 
conveniences will often find it one of the best pro- 
cesses. Any tub or box holding water enough to 
allow the whole body to be immersed, with the limbs 
extended, answers the purpose. A very good plunge 
can be made of a large cask cut in two near the mid- 
dle. It is a useful precaution to wet the head before 
taking this bath. 

" 13. Drop-Bath. — A vessel, filled with very cold 
water, is furnished with a small aperture through 



Hygienic Treatment. 237 

which the water falls in drops. It is adapted to torpid 
muscles, paralytic limbs, tumors, etc. It should be 
followed by active friction. 

"14. The Sweating-Pack. — To produce perspiration, 
the patient is packed in the flannel blanket and other 
bedding, as mentioned in No. 1, omitting the wet 
sheet. Some persons will perspire in less than an 
hour ; others require several hours. This is the se- 
verest of the Water-Cure processes, and, in fact, is 
very seldom called for. The warm, hot, or vapor- 
baths are, in most cases, preferable. 

" 15. Head-Bath, — The patient lies extended on a 
rug or mattress, the head resting in a shallow basin or 
bowl, holding two or three inches of water, the shoul- 
ders being supported by a pillow. It is principally 
employed in chronic affections of the head, eyes, and 
ears. "Wet cloths applied to the head, the " pouring- 
bath," and the " wet cap" are good substitutes. 

"16. The Pouring Head-Bath. — The patient lies 
face downward, the head supported by an attendant, 
projecting over the side of the bed, which is protect- 
ed by a sheet or blanket thrown around the patient's 
neck ; a tub is placed under the head to catch the water, 
which is poured from a pitcher moderately, but stead- 
ily, for several minutes, or until the head is well cooled, 
the stream being principally applied to the temples and 
back part of the head. It is useful in severe cases of 
sick headache; in the early stage of violent choleras; 
in the early stages of fevers, when attended with great 
gastric irritation or biliary disturbance. In hysteria, 
apoplexy, delirium-tremens, nose-bleeding, inflamma- 
tion of the brain, ophthalmia, otitis, etc., it has been 
employed with advantage. 

" 17. Fountain, or Spray-Bath. — This consists of a 



238 DlPTHERIA. 

number of small streams of water directed to a partic- 
ular part of the body. It may be regarded as a gen- 
tle douche or local shower. It is intended to excite 
action and promote absorption in the part or organ to 
which it is applied. 

" 18. The Shower-Bath. — This needs no descrip- 
tion. It is not frequently used in Water-Cure, but is 
often very convenient. Those liable to a u rush of 
blood to the head," should not allow much of the 
shock of the stream upon the head. Feeble persons 
should never use this bath until prepared by other 
treatment. Placing the feet for a few minutes in 
warm water, before taking the shower, is a good pre- 
paratory measure for feeble persons. Standing in 
warm water, ankle deep, will materially lessen its 
shock on the brain and nervous system. 

" 19. Nasal, Mouth, and Eye Baths. — Drawing 
water gently up the nostrils and ejecting it by the 
mouth, holding water in the mouth, and holding the 
eyes open in water of a temperature suited to the case, 
are the processes indicated by these terms. They are 
useful in relaxed and inflammatory affections of the 
mucous membranes and other structures of the parts. 

" 20. Arm and Leg Baths. — The limbs may be held 
in any convenient vessel containing the requisite depth 
of water. These baths are useful in cases of fever 
sores, chronic ulcers, inflammatory affections of the 
joints, etc. 

" 21. Yapor-Bath. — Hot stones or bricks may be 
employed to generate vapor or steam. The patient 
may sit naked on an open-work chair, with blankets 
pinned around the neck ; a small tub or a common 
tin pan, holding a quart of water, is placed under the 
chair, and red-hot bricks or stones occasionally put in 



Hygienic Treatment. 239 

the vessel, so as to keep the vapor constantly rising 
from the surface of the water. Another very simple 
plan is this : Procure a one-gallon tin boiler, with a 
half-inch tin pipe, having two or three joints and a 
single elbow. The boiler may be heated on any ordi- 
nary stove, grate, or furnace, and the pipe so attached 
to it as to convey the steam under the chair in which 
the patient sits, covered from the neck downward with 
blankets. It may be employed from ten to thirty min- 
utes, according to the amount of vapor generated. 

" 22. Am- Bath. — The whole body is suddenly ex- 
posed to cool or cold air, or even to a strong current, 
and an excellent and invigorating process it is in many 
cases. There is no danger from it, provided the sur- 
face has a comfortable glow or temperature at the time, 
and the circulation is maintained by active exercise. 
Friction with the hand, a sheet, towel, or flesh-brush, 
is beneficial at the same time. 

" 23. Bandages and Compresses. — These are wet 
cloths, applied to any weak, sore, hot, painful, or dis- 
eased part, and renewed so often as they become dry or 
very warm. The best surgeons have, in all ages, em- 
ployed ' water-dressings' alone in local wounds, injuries, 
and inflammations. They may be warming or cooling 
to the part, as they are covered, or not, with dry cloths. 

" 24. The Wet-Girdle. — Three or four yards of 
crash toweling make a good one. One half of it is 
wet and applied around the abdomen, followed by the 
dry half to cover it. It should be wetted so often as it 
becomes dry. It is extensively employed in bilious 
and dyspeptic affections, female weaknesses, etc. 
When required to be worn for a long time, it should, 
after the first few weeks, be omitted occasionally, or 
worn only a part of each day, so that the skin over 



240 DlPTHERIA. 

which it is applied will not become too tender. It 
should not be worn when it occasions permanent chil- 
liness. 

" 25. The Chest-Wrapper. — This is made of coarse 
linen, to fit the trunk like an under-shirt, from the 
neck to the lower ribs ; it is applied so wet as possible 
without dripping, and covered by a similar dry wrap- 
per, made of Canton or light woolen flannel. It re- 
quires renewing two or three times a day. It is useful 
in most cases of pneumonia, asthma, consumption, 
bronchitis, etc. The same precautions apply to its 
prolonged employment as mentioned under the head 
of the wet-girdle. 

"26. Fomentations. — These are employed for relax- 
ing muscles, relieving spasms, griping, nervous head- 
ache, etc. Any cloths wet in hot water and applied so 
warm as can be borne, generally answer the purpose ; 
but flannel cloths dipped in hot water, and WTimg 
nearly dry in another cloth or handkerchief, so as to 
steam the part moderately, are the most efficient seda- 
tives. They are usually employed from five to fifteen 
minutes. They are useful in cases of severe constipa- 
tions, colic, dysmenorrhea, hysteria, etc. 

" 27. Refrigeration. — One part of common salt to 
two parts of snow or pounded ice makes a good freez- 
ing mixture. It is inclosed in a very thin cloth, and 
applied for a few minutes, until the requisite degree 
of congelation has taken place. It is useful in felons, 
styes, malignant tumors and ulcers, fever sores, can- 
cers, and in some forms of neuralgia and rheumatism. 

" 28. Wet Dress Bath. — This is a method of self- 
packing, enabling the patient to dispense with the 
services of an attendant. A linen sheet is fashioned 
into the form of a night-dress, with large sleeves, and 



Hygienic Treatment. 241 

after the bed is prepared, the dress can be wet and put 
on ; the patient can then get into bed and wrap him- 
self sufficiently to secure a comfortable reaction. 

" 29. Electro- Chemical Bath. — A copper-lined 
bath-tub is necessary for this process. The patient is 
immersed in warm water up to the neck ; one hand is 
brought in contact with the positive pole of a strong 
galvanic battery, the negative pole being in contact 
with the metallic lining of the tub. The water is usu- 
ally acidulated, though in some cases alkalies are em- 
ployed. From half a pint to a pint of nitric acid is 
put into, the water for each bath. It should not be 
mixed with the water until the galvanic circuit is com- 
pleted, either by having the patient in connection with 
the poles of the battery, or these in contact with the 
copper-lining of the bath-tub. The patient may re- 
main in the bath from ten minutes to half an hour. 
This bath is very useful in a torpid condition of the 
skin with low circulation ; in glandular obstructions; 
scrofulas, rheumatic and gouty affections ; in chronic 
congestions of the liver, and to aid the elimination of 
mineral medicines and other poisons. 

" 30. Injections. — These are warm or tepid, cool or 
cold. The former are used to quiet pain and produce 
free discharges ; the latter to check excessive evacua- 
tions and strengthen the bowels. For the former pur- 
pose so large a quantity should be used as the bowels 
can conveniently receive ; and for the latter purpose 
only a small quantity — so much as can be conveniently 
retained. Small enemas of very cold water are highly 
serviceable in cases of piles, prolapsus, fissures, etc. 
The self-injecting syringe is the most convenient in- 
strument. "With a rectal, vaginal, and intra-uterine 
tube, it will answer all possible purposes, for old or 

11 



242 DlPTHERIA. 

young, male or female. These articles can all be fur- 
nished for $3. 

" 31. General Bathing Eules. — Never bathe soon 
after eating. The most powerful baths should be taken 
when the stomach is most empty. No fall bath should 
be taken less than three hoars after a fall meal. Great 
heat or profuse perspiration are no objections to going 
into cold water, provided the respiration is not dis- 
turbed, and the patient is not greatly fatigued or ex- 
hausted. The body should always be comfortably 
warm at the time of taking any cold bath. Exercise, 
friction, dry-wrapping, or fire may be resorted to, ac- 
cording to circumstances. Yery feeble persons should 
commence treatment with warm or tepid water, gradu- 
ally lowering the temperatare. All shocks, such as 
shower-baths, douches, plunges, etc., should be avoided 
by every feeble and irritable invalid ; by consumptives 
in the second and later stages; by those who are liable 
to great local determinations, or congestions, as " rash 
of blood to the head," bleeding from the stomach or 
lungs, etc. ; in displacements of the bowels or uterus ; 
during the menstrual period of females ; during any 
considerable crisis or critical effort ; after the crisis or 
" turn" of any fever, or other acute disease ; during 
the existence of any powerful emotion or excitement ; 
soon after eating or copious drinking ; in all cases at- 
tended with profuse discharges, as diarrhea, cholera, 
diabetes, hemorrhages ; during the suppurative stage 
of extensive abscesses or ulcers. The heat or feverish- 
ness which may attend any of the conditions or dis- 
eases above-named should always be abated by tepid 
effusions or spongings. It is dangerous to employ the 
w T et-sheet pack, in prolonged or violent fevers, after 
the crisis or turn of the fever. Many errors have been 



Hygienic Treatment. 243 

committed in ignorance of this rule. Never eat imme- 
diately after bathing. 

" 32. Duration of Baths. — Many errors are com- 
mitted by remaining in cold baths for too long a time. 
I have known cases in which dyspeptics and consump- 
tives, at Water-Cure establishments, were kept in cold 
sitz-baths for two hours at a time, once or twice a day. 
This was intended as a derivative measure, but it 
worked very injuriously for the patients. Derivative 
baths, like all others, must be determined by the con- 
dition of the patient, not by the thermometer nor chro- 
nometer. Sitz-baths of a mild temperature should sel- 
dom be prolonged beyond twenty minutes ; more fre- 
quently ten to fifteen minutes are preferable. It is 
better to repeat all bathing appliances frequently, than 
to make violent impressions less frequently. Plunges, 
douches, and showers, if the water is cold or cool, 
should not ordinarily be continued more than a min- 
ute ; when the temperature of the water is temperate, 
or tepid, they may be taken from five to ten minutes. 
Tepid half-baths should usually be taken from five to 
.ten minutes. Sitz-baths, foot-baths, head-baths, arm 
and leg baths, etc., may vary from five to thirty min- 
utes. But, as already intimated, regard must always 
be had to the temperature of the water and the circu- 
lation of the patient." 

In the premonitory stage of diptheria, when the pa- 
tient is affected with rigors or chilliness, or these with 
alternate and irregular flushes of heat, a full warm 
bath, as warm as the patient can comfortably bear, for 
ten or fifteen minutes, should be employed if practica- 
ble. If this is impracticable, the warm hip-bath and 
the hot foot-bath are the best substitutes. If these are 
not available, warm fomentations to the abdomen, and 



244 DlPTHERIA. 

bottles of hot water to the sides and feet, should be re- 
sorted to. 

If there is at this time pain or soreness of the throat 
without much heat, fomentations should be applied 
externally for ten or fifteen minutes, followed by 
the cold wet compress covered with a dry towel or 
cloth ; and this should be re- wet and re-applied as 
often as it becomes warm or nearly dry. The patient 
should keep entirely quiet at this time, avoiding every- 
thing in the shape of food, condiments, stimulants, and 
medicines, swallowing nothing but pure water, and of 
this only so much as is demanded by the thirst. The 
temperature of the water for drinking may be that 
which is most agreeable to the patient. 

"When the hot stage of the fever is fully developed, 
the tepid half-bath, the tepid ablution, or the wet-sheet 
pack may be resorted to. The wet-sheet pack is best 
adapted to those cases in which the heat and dryness 
are uniform over the whole surface, and the patient is 
not greatly prostrated. But with more feeble patients, 
and when the external heat is moderate or unequal, 
the tepid ablution should be preferred. The tepid 
half-bath is applicable to the same cases as the wet- 
sheet, and is only preferable when the attendants do 
not well understand the management of the packing 
process. The temperature of the water should be cool, 
but not very cold — from 75° to 85° Fahrenheit. Either 
of the baths may be repeated as often as occasion re- 
quires ; that is, as often as the external temperature of 
the patient rises much above the normal standard. 
The patient should be put to bed immediately after 
each bath and kept warm and comfortable ; much 
sweating, however, is to be avoided, although a very 
moderate perspiration may be desirable. Too much 



Hygienic Treatment. 245 

care can not be taken to keep the feet warm and the 
head cool ; and if there is the least tendency to cold- 
ness of the lower extremities and heat of the head, hot 
bottles should be applied to the feet and cold wet 
cloths to the head. 

"When there is much pain, heat, or swelling of the 
throat, or when the little patches of fibrinous exuda- 
tion become visible on the mucous membrane of the 
tonsils, or elsewhere, the local treatment must be 
varied accordingly. Cold applications must be now re- 
sorted to, and employed thoroughly and perseveringly 
until the morbid secretion is arrested. Sips of very 
cold water may be taken frequently, or, what is still 
better, bits of ice may be put into the mouth and al- 
lowed to melt away, while the throat is enveloped in 
cold wet cloths. The indication now is to check the 
violence of the inflammation, and thus arrest the exu- 
dation of the membranous material ; and there is no 
way to do this so certainly and so effectually as to re- 
duce the morbid heat below the point which is essen- 
tial to the excretion of coagulable lymph. This plan 
has been employed in thousands of cases of croup 
with almost uniform success. And in the ulcerated 
sore throat of malignant scarlet fever, it is the only re- 
liable resource. 

If the patient is at any time troubled with harassing 
cough, difficult expectoration, or laborious respiration, 
or all together, after the violence of the inflammation 
has subsided, warm-water-drinking, to the extent of 
inducing vomiting if need be, should be resorted to. 
And in the later stage of the disease, when the con- 
creted exudation is firmly adherent to the mucous sur- 
face, or has extended widely in the bronchial tubes, 
warm fomentations to the chest and throat are proper, 



246 DlPTHEEIA. 

To these cases the moist atmosphere, or vapor, as rec- 
ommended by Dr. Sayre, is especially adapted. 

Although the fever may in some cases be violent, so 
far as severity of symptoms is concerned, and the 
throat affection intense, so far as the inflammatory ac- 
tion is concerned, yet as the diathesis is always atonic 
or asthenic, these conditions will much sooner yield to 
the proper cooling remedies named than they will in 
the truly entonic or sthenic diathesis. In what is prop- 
erly denominated entonic visceral inflammation, that 
is, enteric or sthenic fever, with active or phlegmo- 
nous inflammation, patients will frequently bear to 
be packed in double wet-sheets, with advantage ; and 
these may frequently be repeated two or three times 
in twenty-four hours. But the preternatural heat is 
never so persistent in diptheria. The wet-sheet pack 
rarely requires more than one application in twenty- 
four hours, and it seldom happens that more than two 
or three repetitions of this process are necessary to 
materially mitigate the violence of the febrile action ; 
after which, should the skin incline to feverishness, the 
tepid ablution will be sufficient. 

Abundance of pure f res h air is quite as important 
in the treatment of diptheria as are the bathing pro- 
cesses. No doubt the contagiousness or non-conta- 
giousness of the disease depends very much on the 
means which are employed to ventilate and cleanse 
the apartment. The patient should be kept comfort- 
able, by means of bed-clothes, and fire if necessary, but 
on no consideration should all of the windows and 
doors be closed for a moment. The safety of others as 
well as of the patient may depend on this precaution. 
In close rooms, and in underground apartments, where 
free ventilation by doors and windows is impossible. 



Hygienic Treatment. 247 

the air of the place may be purified to a great extent 
by swinging the door vigorously forward and back- 
ward. In this way, in the crowded tenement houses 
of our cities and large villages, fresh air may be sup- 
plied and the accumulated miasms expelled, when 
there is no other possible method for " raising the 
breeze." 

The purifying and invigorating influence of light and 
sunshine should never be disregarded. They are use- 
ful in nearly ail morbid conditions, and of especial 
value in the management of putrid and infectious 
febrile and inflammatory diseases. When practicable, 
the rays of the sun should be admitted freely into the 
sick chamber, and, during the day, the room should 
be as well lighted as possible. But at night, when the 
external senses of the patient need quiet and repose, 
light should be excluded ; nor should the talking or 
whispering of watchers be allowed in the room. 

Rest is an important element in the Hygienic treat- 
ment of disease. And there is no remedial resource so 
little understood and so generally disregarded as this. 
A majority of physicians seem to have no idea of its 
necessity or value ; or if they do, they ignore it alto- 
gether in practice. Indeed, rest is out of the question 
if the patient must be disturbed and disquieted with 
some dose, or drug, or slop, every hour or every half 
hour, and even awakened out of sleep, if he is so for- 
tunate as to be able to slumber, to swallow something 
w T hich does more harm than good. 

The chief point of skill in the true physician is to 
know when to let the patient alone. It is easy to perceive 
morbid phenomena, and to combat symptoms ; but to 
know when Nature is doing just right, and when she 
should not be interfered with, require judgment and 



248 DlPTHERIA. 

discrimination. " Let-alone-ativeness" is the chief 
merit of Homeopathy. The patient is amused with 
infinitesimal placebos, while Nature has time and 
opportunity to remove the causes of disease, and then 
the cure results as the necessary consequence of having 
nothing more for the vis medicatrix to do. 

So far as food and diet are concerned, very little 
need be said. As I have already intimated, the prac- 
tice of stuffing the patient continually on what the 
doctors, with consistent absurdity, call " nourishing 
diet," is exceedingly pernicious. During the acute 
stage of the disease, while the fever is violent and the 
inflammation severe, no food can be digested, and 
none should be taken. As the fever subsides, the 
patient may be allowed a little gruel, and good fruit, 
to be followed, as convalescence advances, with such 
farinaceous articles as mealy potatoes, beans, peas, 
unleavened bread, etc. Baked apples, tomatoes, 
stewed or raw, sweet oranges, etc., may generally be 
allowed as freely as the patient desires, and, until the 
crisis of the disease is fairly passed, no other food is 
required. 

Drink may be taken according to thirst ; but when 
there is great thirst with a disposition to vomit, very 
small draughts should be taken and frequently re- 
peated. There is no objection in such cases to the 
juices of acid and subacid fruits, properly diluted, as 
lemon juice, apple water, oranges, etc. Dried berries, 
stewed and slightly sweetened, will answer, in some 
cases, for both victuals and drink. In New York 
city, and probably in most other parts of the country, 
dried blackberries, raspberries, and whortleberries can 
be had in abundance in the winter season. Preserved 
berries can also be found, nearly as fresh and savory 



Hygienic Treatment. 249 

as when first picked from the bushes. The value of a 
really frugivorous diet, in febrile diseases, has never 
been sufficiently appreciated. 

Enemas may be necessary in the early stage of the 
disease, but are seldom required afterward. In the 
outset of the disease, provided there has been no 
diarrhea, the bowels should be moved freely with an 
injection of tepid water; and subsequently only when 
a sense of fullness and distention of the abdomen indi- 
cates the presence of accumulated fecal matters. 

When vomiting becomes a troublesome symptom or 
complication, small bits of ice may be occasionally 
swallowed, or frequent sips of cold water taken, and a 
cold wet towel covered with a dry cloth should be 
applied over the region of the stomach. 

Diarrhea can be relieved by means of warm fomenta- 
tions to the abdomen, and small enemas of cool or cold 
water, administered immediately after the evacuations. 
The patient should keep the horizontal posture, and be 
as quiet as possible. 

Albuminaria does not require any special medica- 
tion. 

Hemorrhages can generally be promptly checked 
with cold applications. 

Extreme swelling of the glands of the neck requires 
the constant application of wet cloths to the part. 

Coma may be relieved by cold applications to the 
head and warm ones to the feet. In extreme cases, 
fomentations to the abdomen may be employed advan- 
tageously. 

The sequelce of diptheria demand only a strict atten- 
tion to the general health, except so far as they are the 
effects of drug-medicines, and then all the appliances 
for purification must be brought into requisition. 

11* 



250 DiPTHERIA. 

That the plan of treatment I have now detailed is 
successful, I have not only my own experience, and 
that of other physicians of the Hygeio-Therapeutic 
School, to offer as evidence, but I have also the testi- 
mony of some of the drug doctors themselves. As an 
illustration, I will give, in full, an article published in 
the Dansville (N. Y.) Herald : 

" DlPTHERIA, SORE THROAT, AND QUINSY SUCCESSFULLY 
TREATED BY THE LOCAL APPLICATION OF ICE. 

" Dansville, Feb. 18, 1861. 

" Mr. Editor — Dear Sir : Allow me, through the 
columns of your valuable journal, to make some prac- 
tical remarks on the subject of diptheria. I shall con- 
fine myself to the consideration of its early symptoms, 
and its early or abortive treatment. I do not propose 
to enter into a lengthy discussion as to what is or what 
is not diptheria, except so far as to make myself under- 
stood as to the treatment, that being what I most de- 
sire to bring to the notice of your patrons and the 
public generally. Hence, sir, what I have to say will 
be as strictly practical as may be. If, by any course 
of treatment, the early or premonitory symptoms can 
be stopped, then we have no diptheria. 

" Now, sir, I have had this disease to treat constantly 
for the last twenty months, and what I have to say is 
the result of actual observation and experience ; there- 
fore it is not the result of mere speculation and theory, 
of which we have had quite enough. I conceive it to 
be about time for somebody to bring the subject down 
to facts, and these facts sustained by a uniform success 
in practice, applied according to the rules which ex- 
perience has found necessary to be observed. 

" Then, sir, we lay it down as an axiom, that dip- 
theria in its early stages is nothing more nor less than 



Hygienic Treatment. 251 

an inflammation, and that there never was a case of 
diptheria without a preceding inflammation to a 
greater or less extent, and that the inflammation has a 
termination peculiar to itself. 

" Again we lay it down as an axiom, that no man, 
however close his observation, can distinguish between 
an inflammation, the termination of which will be 
diptheria, and one the termination of which will be 
pus, as in common tonsillitis, quinsy, or gangrene and 
sloughing, as in putrid sore throat. While the inflam- 
mation is being developed previous to its termination, 
the result can not be foretold with any degree of cer- 
tainty. That inflammation of the throat results in one 
of the three mentioned forms, daily experience veri- 
fies ; that is to say, in an exudation which immediately 
becomes organized tissue, forming the false membrane, 
which constitutes a case of diptheria. This membrane 
may be in small and separate patches, or it may ex- 
tend all over the back part of the mouth and upper 
part of the windpipe, and even, as it sometimes does, 
travel down into the smaller bronchial tubes. It is 
the formation of this false membrane which constitutes 
a case of diptheria. 

" Then as to the other two terminations of inflam- 
mation of the throat (and one that is scarcely less fatal), 
we may say that one is that of mortification or slough- 
ing, called putrid sore throat, the other is in the forma- 
tion of matter or pus ; this is designated quinsy or 
tonsillitis. 

" Having thus briefly stated what experience bears 
me out in saying in relation to the early stages of this 
truly frightful disease, before stating the treatment 
proper, I wish to say a word in relation to what I 
think an erroneous and unsafe theory — that is, that the 



252 DlPTHEEIA. 

disease is constitutional, and that the soreness of the 
throat is but the local manifestation of a general or 
constitutional diseased action. Now, sir, I hold the 
reverse to be the truth ; that is, that the disease of the 
throat is the disease, and that the constitution becomes 
affected by absorption of the poison from the throat, 
the same as in the case of vaccination, when the mere 
speck of matter inserted under the skin of the arm pro- 
duces a general affection, viz., kine-pox. I hold this 
theory of the primary taint of symptoms to be unsafe, 
from the fact that it misleads the physician, and his 
poor patient has been caused to swallow large doses 
of drastic purges and the like, in order, as he says, to 
rid the poor victim of some imaginary poison. But 
above all it has caused him to neglect the proper treat- 
ment of the throat trouble, and thereby allowing the 
only chance to slip ; and this very poison which is 
so much dreaded, time to absorb into the system at 
large, and this to bring on a fatal typhoid train of 
symptoms. 

" Then to recapitulate. Diptheria, in its early 
stages, is but an inflammation, having a termination 
peculiar to itself, yet subject to the same laws that 
govern other inflammations, viz., heat, redness, and 
swelling, producing soreness just in proportion to the 
amount of inflammation, and the fever which attends 
is in exact ratio to the amount of local or throat 
trouble. Believing that I have made myself capable 
of being understood, I will now proceed with the 
treatment. 

" First, then, envelop the neck in cloths wrung out 
of cold water (it is not the water but the cold), chang- 
ing them as often as they get warm. If there is much 
swelling near the angle of the jaw, apply a bladder 



Hygienic Treatment. 253 

with a handful of snow, so arranged as to form a small 
surface. This should be placed directly over the ton- 
sils. So much for the external applications. 

" If there is not much swelling externally, the cold 
cloths or snow may be omitted, and the case may be 
trusted to internal applications. The patient should go 
to bed, and laying upon the back should take a small 
piece of ice into the mouth and allow it to settle as far 
down as possible without swallowing it. When this has 
melted, he should spit out the water and have a fresh 
piece of ice applied. This will require a faithful and 
attentive nurse. The pieces of ice should be about as 
large as the first joint of the finger. By pursuing this 
course in the early stages of the disease, it will be 
cured in from twelve to twenty-four hours. If the dis- 
ease has got a little further advanced, yet in its inflam- 
matory stages, with high febrile action, put the patient 
into a warm bath, keep him there until he feels faint ; 
take him out, wrap him in warm flannel blankets and 
sweat him for one or two hours, after which maintain 
a gentle perspiration for three or four days ; for be it 
known that absolute rest for this length of time is 
essential. The ice is to be continued at the same time. 

" This may seem to be a very simple treatment for 
so formidable a malady ; but that is a mistake, for we 
have not a more powerful remedial agent than ice when 
properly applied ; besides being formidable it is capa- 
ble of perfect management, and all that is necessary is 
to graduate the amount of cold to the degree of inflam- 
mation. It also has another valuable feature, that of 
always being on hand, especially at this time of year. 

" I am confident, from a long experience in the use 
of this remedy, that if people will observe and apply as 
above directed, that diptheria will be shorn of its terror 



254 DlPTHERIA. 

and many a valuable life saved. Remember that it 
must be used early, from the first accession of throat 
symptoms, and persevered in until they are removed. 

" This treatment may and probably will meet with 
the same reception that all great principles have when 
first brought before the world of mind — that is, that it 
is an innovation, and some of the wise old ones will 
shake their heads doubtingly. But I hold that dis- 
ease when it can be cured should be, whether it be ac- 
cording to authority or without authority. Sir, where 
would be the mighty improvements that have been 
made in medicine, if nobody should take a step beyond 
authority ? Respectfully yours, 

« Z. H. Blake, M.D." 

I am decidedly opposed to sweating any diptheritic 
patient for one or two hours. Many patients will bear 
it, and all may if the sweating be not too profuse ; nor 
would I make it a point to keep the patient in the warm 
bath until he feels faint. A warm bath of ten or fif- 
teen minutes' duration is sufficient, and if all faintness 
is avoided so much the better. It is well, afterward, 
to keep the patient quiet, and the skin in a moist, per- 
spirable state ; but anything like profuse sweating is 
to be deprecated. 

Dr. Blake makes no allusion to " Water-Cure," or 
" Hydropathy," nor does he give the least hint that he 
ever knew or heard of a case of diptheria being treated 
with cold water and colder ice, with external warm or 
cold bathing, and without drugs of any kind, except 
in his own practice. So far as one can infer from his 
article, this practice with him is entirely original. 
The statement, " I have had this disease to treat con- 
stantly for twenty months, and what I have to say is 
the result of actual observation and experience," may 



Hygienic Treatment. 255 

be interpreted in various ways. His observations may 
have been made on the cases which were treated by 
other physicians, and who have treated it in the way 
he recommends. 

At all events, it is true that many cases of diptheria 
were treated in Dansville, and several of them at 
the water-cure of Dr. Jackson, in that place, and all 
successfully, previous to the date of Dr. Blake's arti- 
cle. And it is also true that the Water- Cure Journal, 
which circulates largely in Dansville, had previously 
and repeatedly advocated a similar plan of treatment. 

The theory advanced by Dr. Blake, that the causes 
of the disease are essentially local, and that the consti- 
tutional disturbance results from the absorption of the 
local infection, has been sufficiently refuted in the pre- 
ceding part of this work. But as Dr. Blake predicates 
on the theory which he adopts a very plausible argu- 
ment against the employment of drug-remedies, it seems 
needless to correct the error, so far as diptheria is con- 
cerned. But the principle involved applies to other 
disease! — indeed, to all diseases. 

Dr. Blake objects to the internal use of poisonous 
drugs, because the causes of the disease are not in 
the blood, but on the mucous membrane of the throat. 
Will not this reasoning apply to other diseases as well 
as diptheria ? Again, if drug-medication is proper per 
se, and if diptheria is primarily a mere throat affection, 
why not apply drugs to the throat ? If drugs are 
really and properly curative agents, here is one of the 
best imaginable opportunities for employing them ju- 
diciously and successfully, because we can see the dis- 
eased part, and have the evidence of our senses as to 
the modus operandi and effects of the medicines. 
Here is inflammation, for which bleeding, niter, anti- 



256 DlPTHERIA. 

mony, digitalis, salts, veratria, arnica, aconite, gelsemi- 
num, and all the host of antiphlogistics and narcotics 
have such a reputation for curing ; and here is (accord- 
ing to Dr. Blake) a locally generated virus, and what 
mortal doctor of the drug school ever conceived the 
possibility of arresting, correcting, suppressing, de- 
stroying, or killing, or curing a virus without a specific 
drug, or a counter-poison, or an " alterative," without 
mercury in some form ? 

But, no. Dr. Blake proposes simply to cool the 
virus, to refrigerate the inflammation. He relies on 
temperature alone to destroy the infection, arrest the 
inflammation, prevent or remove the fever, and restore 
the patient to health. He is right in practice, but 
wrong in theory. Should he adopt the true theory and 
give the correct explanation, he could not long main- 
tain before the world the position of drug doctor. 

Dr. Blake reasons that, because the disease, or its 
cause, is local, it can be cured without drugs. But, 
admitting the disease, or its cause, to exist in the blood, 
why can not it also then be removed or cured without 
drugs ? Dr. Blake's practice is revolutionary ; and I 
am unwilling that an ingenious sophistication shall be 
allowed to save the theory of drug-medication from its 
damaging influence. 

In all the places which I have visited during the last 
year, I have made special inquiries as to the prevalence 
of diptheria, the manner in which it has been treated 
by the physicians, and the rate of mortality. And all 
the information I have been able to collect from others, 
agrees precisely with my own observations and expe- 
rience. Wherever the Hygienic plan of treatment, 
substantially as recommended in this work, has been 
adopted at the commencement of the disease, and per- 



Hygienic Treatment. 257 

severed in to the end, to the total exclusion of all drug- 
medication, local or constitutional, no death has yet 
come to my knowledge. In three or four instances, 
where the patients were badly scrofulous, or very gross 
in dietetic habits, and where the physician was not 
called until the membranous exudation had extended 
to the bronchial tubes, the cases have terminated fatally. 
But such can hardly be regarded as exceptions to the 
uniform success of Hygienic treatment. 

I do not claim, nor do I believe, that all eases are 
curable by the means which I recommend. No doubt 
there are cases which are incurable by any means 
whatever. There are, undoubtedly, persons so gross 
in body, so depraved in blood, so frail in organization, 
or so feeble in vital resources, that the existence of 
diptheria necessitates death. But these cases are ex- 
ceptions, and rare ones too, to the general rule. 

I have heard from more than one dozen of the grad- 
uates of the New York Hygeio-Therapeutic College, 
who have treated each rom one to twenty cases of 
diptheria and putrid sore throat, without as yet losing a 
single patient. 

While riding on the cars from Iowa City to Chicago, 
in the month of January last, I made the acquaintance 
of Mr. C. Manfull, of Augusta, Ohio, who was return- 
ing from a trip to the West. Mr. Manfull informed 
me that, seven or eight years ago, he purchased the 
" Hydropathic Encyclopedia," and subscribed for the 
Water-Cure Journal, since which time he has treated 
his own and many of his neighbors' children, when 
sick of croup, diptheria, or any form of sore throat, 
w r ith invariable success, having never lost a patient. 
He informed me also that an eminent allopathic physi- 
cian in Steuben ville, Ohio, where the diptheria had been 



258 f DlPTHERIA. 

extensively prevalent and very fatal, had possessed 
himself of the " Encyclopedia," adopted the Hygienic 
treatment, and abandoned all drug-medication, after 
which very few deaths* occurred in the place. He 
stated, moreover, that Dr, Beaumont, of Cumberland, 
Va., had treated many cases of crorrp, diptheria, and 
malignant scarlet fever hygienically, and had not lost 
one patient. Dr. Beaumont has delivered public lec- 
tures on "Hygienic versus Drug-Medication," with 
good effect. 

TRACHEOTOMY. 

As a last resort, when the false membrane is so 
obstructing the air-passages as to endanger imme- 
diate suffocation, this operation is recommended by 
some authors. It is at least highly probable that some 
lives have been saved by the operation, but there is 
reason, too, to believe that, in some cases, life has been 
destroyed by it. It is not always possible to determine, 
whether the patient survives the operation or not, what 
influence the measure had in determining the result. 

During the year 1856 there were fifty-four opera- 
tions of tracheotomy for croup, at the Children's Hos- 
pital in Paris. Of these cases fifteen recovered. M. 
Guersant testifies that, in the cases in which he has 
operated, about one third have recovered. M. Bou- 
chat operated on one hundred and sixty, and only five 
were saved. M. Bretonneau performed the operation 
in twenty cases, of which six recovered. M. Velpeau 
operated ten times, and two of his patients recovered. 
M. Perit operated in six cases, and in three of the 
cases the patients were saved. 

The results of three hundred and eighty operations, 



Tracheotomy. 259 

reported by M. Chaillon, were, two hundred and 
ninety-four deaths, and eighty-six recoveries. 

The statistics of the Hospital des Enfants show a 
mortality of five to one. 

In Great Britain, so far as the statistics have been 
reported, the results of the operation have been some- 
what less favorable than in France. 

The statistics of American authors are exceedingly 
meager on this subject, but do not vary materially from 
the reports of the French and British hospitals. 

Dr. Gross, of Louisville, Kentucky, has published 
the particulars of one hundred and seventy-six cases 
of foreign bodies in the larynx ; in sixty-eight of these 
cases the operation of tracheotomy was performed, 
with a mortality of only eleven per cent. But the 
success or propriety of the operation, in these cases, 
must be predicated on very different premises from 
those which apply to the necessity or utility of the 
operation in diptheria. 

It is true that the operation of tracheotomy is not in 
itself a very difficult nor dangerous operation in adults, 
yet with young children the case is very different, and 
requires the utmost surgical skill and dexterity. And 
when the patient is extremely exhausted, the pain and 
alarm necessarily attending the operation might be 
sufficient to turn the scale against the patient. 

Many authors have objected to the operation on the 
ground that it is apt to induce severe bronchitis, or 
greatly to aggravate the previously existing inflam- 
mation. 

The only condition in which the operation can be 
called for or justified is when the diptheritic exudation 
has extended to the larnyx, and has become so firmly 
concreted and adherent to the membrane as to threaten 



260 DlPTHEKIA. 

death by suffocation. In these cases it is obviously 
possible to keep up the respiration by means of an ar- 
tificial opening into the windpipe, until the false mem- 
brane can be cast off and expelled. It is, of course, 
a desperate expedient, and so much so that many prac- 
titioners of eminence and experience proscribe it en- 
tirely. There can be no doubt that the operation has, 
in many cases, probably in a great majority, been re- 
sorted to when the patient was actually moribund, so 
that the deaths were scarcely at all influenced by it. 

The proper time for performing the operation, pro- 
vided it be proper in any case, is not very precisely 
determined by the authors who have written on the 
subject. " We should not wait until the case is des- 
perate, or the patient in a dying condition," says one ; 
nor, says another, " should we attempt the operation 
too early, before other remedies had been fairly and 
completely tested." 

But as to what precise time may be regarded as the 
proper " middle period," and how we are to know 
when all other remedies have been " fairly and com- 
pletely tested," we are left entirely in the dark. Dr. 
Slade quotes approvingly the following rule as to time : 
" so soon as ever we feel that our remedies are too 
tardy to overtake the disease." 

This may be an excellent rule for the conscience, but 
a very poor one for the judgment. A physician may 
practice very conscientiously, yet very injudiciously. 
The important information which the authors do not 
give us is, by what symptoms are we to know when to 
perform tracheotomy ? 

There is, I apprehend, no better rule to be governed 
by in determining this question than the one I have 
already intimated. When the patient is in a state of 



Stimulation vs. Antiphlogistication. 261 

actual suffocation from the presence of the false mem- 
brane in the larynx, and the strength not greatly ex- 
hausted, the operation will be justifiable ; but whether 
it will even then increase or decrease the chance of re- 
covery, is a problem which I regard as by no means to 
be settled by the data before us. 

The operation consists in making an opening into 
the windpipe, a short distance below the larynx, and 
introducing a canula, through which respiration can 
go on. It is important that the canula be large enough, 
or suffocation would soon take place ; and great care 
must be taken to keep the instrument free, or respira- 
tion may cease from a stoppage of the tube. The gen- 
eral custom is to allow the tube to remain four or five 
days, and renew it should difficult breathing recur on 
its removal. 

Tubing of the glottis, an experiment introduced by 
M. Bouchat, has been resorted to by other practition- 
ers. The process consists in inserting into the larynx, 
through the mouth, a metallic tube, through which 
respiration is to be maintained. The most that is pre- 
tended in favor of this operation is, that it may delay 
asphyxia, and perhaps postpone for awhile the neces- 
sity for tracheotomy. 

STIMULATION VS. ANTIPHL0GISTICAT10N. 

I have now placed before the reader all the import- 
ant facts and theories I can find in medical books and 
journals concerning the nature and treatment of dip- 
theria, with the opinions of medical writers and teach- 
ers for or against the various methods of medication 
which have been proposed; and an explanation of the 
Hygienic plan of treatment, with the reasons therefor. 



262 DlPTHERIA. 

But I can not conclude this work satisfactorily to myself 
without a chapter devoted especially to the refutation 
of the gross error of the medical profession, and the 
great delusion of the people, not only as respects the 
nature and treatment of diptheria, but with regard to 
the proper management of all diseases. 

Medical men always act from some recognition of a 
theory, however vague and indefinite it may be. What- 
ever doctrine or hypothesis the physician entertains 
respecting the intrinsic nature of any malady, it will in 
some manner influence his prescriptions at the bedside 
of the patient. 

It is true that a large class of practitioners, finding 
by experience that all the doctrines of medical books 
and schools are unsatisfactory, that all of the practice 
recommended by the standard authorities is uncertain, 
and learning, too, by repeated disappointments, that 
the principles which medical authors teach will seldom 
apply in practice, have ignored all theory, and profess 
to be guided only by facts. Their only guides in the 
treatment of disease are their own observations and the 
experience of their predecessors. But as it happens 
that the observations of medical men are widely dif- 
ferent, and the experience of their predecessors (being 
interpreted so as to agree with whatever theories they 
happen to entertain) is as contradictory as is possible 
to be, these guides seem to be extremely fallacious. 

Medical authors have been contending for several 
centuries whether the stimulating plan of treatment, 
or just the opposite, the antiphlogistic, is the proper 
one for the treatment of certain febrile and inflamma- 
tory diseases, and thus are quite as far from any com- 
mon agreement now as they w^ere three hundred years 
ago. Is it not strange that not one of them has ever 



Stimulation vs. Antiphlogistication. 263 

thought of the primary question which underlies this 
discussion — is either method right ? 

It is taken for granted that if a disease, or the pa- 
tient, will not bear depletion, he must have repletion. 
If he can not endure antiphlogistics, he must be dosed 
with stimulants. If he sinks under reducing treat- 
ment, he must be " supported" with fiery irritants. 
If he will not tolerate bleeding, he must be fed with 
brandy ; and if he can not digest wholesome food, he 
must be stuffed and gorged on such medico- dietetic 
abominations as alcoholized animal broths, grog-and- 
chicken tea, " strong nourishment" of wine-and-soup, 
etc., etc. 

And, on the other hand, if stimulation seems to 
damage the patient, the antiphlogistic plan must of 
necessity do good. If the patient can not bear " sup- 
porting" treatment, he must have the opposite — the 
reducing. If brandy disagrees, bleeding must be in 
order, etc. 

The whole error lies in assuming what is not true. 
Both practices are wrong. The indication of treat- 
ment is to purify, not to stimulate nor antiphlogisti- 
cate. The majority of physicians of the drug school 
recommend bleeding and reducing measures in " in- 
flammatory states" of the system, and alcoholic and 
other stimulants in " typhous conditions." But what 
are inflammatory states, and what are typhous condi- 
tions ? Here all is confusion again. As we have seen, 
some authors regard the fever of diptheria as inflam- 
matory or sthenic, while others regard it as atonic or 
typhoid. And the same disagreement exists as to the 
diathesis of the throat affection. 

The idea that stimulants " support the system," 
" impart energy," or temporarily M augment vitality," 



264 DlPTHERIA. 

is the cause of nearly all the malpractice among med- 
ical men, and of all the dissipation and debauchery in 
the world. Stimulants exhaust vitality, as do anti- 
phlogistics. Brandy and bleeding, opium and niter, 
quinine and antimony, rum and digitalis, capsicum 
and veratria, alike occasion the expenditure and waste 
of vital power, as do all poisons of whatever name or 
nature ; and the notion that a poison which is intrin- 
sically inimical to anything that has organic life, can 
support vitality in any degree or in any sense, is one 
of the wildest vagaries that ever possessed the minds 
of human beings. 

The grand mistake of medical men on this subject 
arises from a false theory of the modus operandi of 
medicines. It is everywhere taught in medical books 
and schools, that medicines act on the different parts 
and organs of the body in virtue of their u inherent 
affinities" for those organs. Nothing can be more 
absurd. The truth is exactly the contrary. The 
living system acts on the medicines. It acts on poisons 
to expel them from the vital domain. Some it expels 
through the skin by a prompt vigorous determination 
of blood and nervous energy to the cutaneous emunc- 
tory ; this process is attended with a feverish state of 
the system and increased heat of the surface ; this 
abnormal excitement or fever is called u stimulation ;" 
and the article or agent which occasions it is said to 
be a " stimulant." 

The effect of the medicine, or the poison, is a fever 
or an inflammation, and nothing else. And a fever 
or an inflammation can not " impart vitality" to the 
system. Nothing can impart what it does not possess. 
It can not " support" the machinery of life. It is the 
same precisely whether the fever or the inflammation — 



Stimulation vs. Antiphlogistication. 265 

the disease — be occasioned by medicine, poison, indi- 
gestible food, " catching cold," a wound, an injury of 
any kind, or any other cause. If it exists at all, it is 
abnormal action ; and abnormal action always expends 
and never augments vital power. 

Antiphlogistics also occasion the waste and loss of 
vital power, but in a different direction, and hence the 
morbid phenomena are very different. They divert 
action from the surface ; in other words, they are re- 
sisted by a determination of blood and nervous energy 
from the circumference of the body to the center, thus 
occasioning symptoms the very opposite of those which 
are called stimulation. The skin is cooler, and the 
pulse weaker, and the muscular power, instead of 
being preternaturally excited, is directly depressed. 
So far as the effects of stimulants and antiphlogistics 
are concerned, stimulants may be said to be indirectly ', 
and antiphlogistics directly, exhausting. 

A similar controversy has long existed in the med- 
ical profession respecting the theory of inflammation. 
By some authors inflammation is regarded as an in- 
creased action of the blood-vessels of the part, or, as 
some teachers express it, " inflammation is an aug- 
mentation of all the vital powers of that part which is 
the seat of it ;" while others contend that it is just the 
contrary, a decreased action of the blood-vessels, or a 
diminution of all the vital powers of that part which is 
the seat of it. And this controversy is apparently no 
nearer a settlement now than it was a thousand years ago. 

The subject, however, seems to be important; for 
if the theory of increased action be true, the antiphlo- 
gistic plan of treatment seems to be indicated : while 
if the doctrine of diminished action be correct, the 
stimulating plan seems to be the reasonable one. 

12 



266 DlPTHERIA. 

But the truth is, neither theory is correct. Inflam- 
mation does not consist essentially in either an in- 
creased or decreased strength of action in the part 
inflamed ; nor is there necessarily any augmentation 
or diminution of the vital energies of the part. In- 
flammation is simply irregular or abnormal action. 
Whether the action be strong or weak, so far as the 
circulation of the blood in the part is concerned, is 
quite immaterial. It may be one or the other in the 
first instance ; but as the disease is prolonged, the 
blood-vessels soon become congested and over-dis- 
tended ; the accumulated blood soon distends their 
coats beyond the power of normal contraction, so that 
debility soon becomes the permanent condition. 

But debility, or decreased action, is not to be reme- 
died by irritating, exciting, and disturbing the vital 
energies with stimulants. To relieve the distended 
and weakened vessels, the destruction must be re- 
moved, and the part allowed to rest. The blood should 
be determined to other parts, not taken out of the body. 

Nor is increased action to be " cured" by antiphlo- 
gistics. It may be " reduced" or subdued, and so may 
all vital action ; but this is only a process of subduing 
the patient. A sick person does not possess too much 
blood, nor too much vital power. Sickness does not 
add to his capital stock of vitality ; nor does a preter- 
natural supply of vital energy ever occasion disease, 
for it never exists. The difficulty, in all cases of in- 
flammation, and in all cases of disease, is in unbalanced 
determination of vital action, and in irregular dis- 
tribution of the blood, as I have heretofore explained. 

This subject has, perhaps, some special importance 
at this time, because the old and oft-exploded doctrines 
of a by-gone age — that bleeding and other reducing 



STIMULATION VS. AnTIPHLOGISTICATION. 267 

measures should be resorted to in treating diptheria, 
because it is an inflammatory affection — and that 
typhus fever is a result and not an attendant of inflam- 
mation, are being revived by modern physicians. 

As an illustration of the propriety of these remarks, 
and as a basis of some further criticisms on the sub- 
ject, the following article, which I find in one of 
the New York newspapers, of large circulation, is 
subjoined : 

"AN INTEKESTING MEDICAL PAPER. 
"soke thkoat, eemittent and typhus feveks. 

" These diseases are to a considerable extent prevail- 
ing, and with some fatality. Any remarks about the 
treatment which tends to cure them will be of service 
to the people. 

" Some time ago, a lecture was delivered at the Med- 
ical College in Twentieth Street, by Dr. Sherrill, on the 
epidemic sore-throat distemper. It was published in 
the Christian Messenger. In the remarks made, it was 
assumed and shown that the throat disease was purely 
of an inflammatory nature ; that the symptoms of 
typhus, gangrene, or what is called diptheria, are effects 
of inflammation, and very likely may be avoided by 
active and suitable means early used to check such an 
inflammation. To effect this, all irritating stimulants 
and alcoholic mixtures are not advisable and are in- 
jurious. A great many facts and authorities are in- 
troduced to sustain this theory ; it is stated that by 
the mode of treatment detailed in this essay, more than 
two hundred cases, in various states and stages, have 
been treated, and that with two exceptions all re- 
covered. 

" In illustration of this subject, it is stated that a 
typhous or gangrenous condition has been represented 



268 DlPTHEKIA. 

to have taken place in the throat disease, for which 
opium, stimulants, and alcoholic articles have been rec- 
ommended and given. It appears that a state of 
typhus is preceded by fever of an inflammatory na- 
ture, as it is in this case, and also in remittent fever 
which precedes a typhoid state when it takes place, 
and that in the first stage it is of an inflammatory or 
congestive type. This is a very interesting position to 
take, and if it is correct, may or ought to have an 
important influence on the treatment. It may be a 
means of inducing prescribers to avoid the free use of 
stimulants and alcohol, which are frequently used. 
There are many authorities named in favor of these 
statements. The address will further explain on this 
subject by an extract : 

" ' It is doubtful whether in this climate any febrile 
disease, in its incipient stage, is of a typhous condition, 
so as to be benefited early by stimulant or alcoholic 
articles. The state of typhus which takes place accord- 
ing to the writer's observations has been the sequence 
of an inflammatory or congestive state of the body 
not arrested in the early stage.' 

" Typhus was considered to be preceded by, and be 
the result of, an inflammation of some of the inner or- 
gans, by Olutterbuck, Armstrong, Broussais, Rush, 
Donaldson and Maygell, and that at first the treatment 
should be to relieve and cure such a condition of the 
body. Remittent fevers, which prevail in summer and 
autumn, in the first stage are of an inflammatory or 
congestive state, and a depleting and refrigerant 
course of treatment is always the most successful. 
This will be a means of checking the progress of the 
case and preventing a state of typhus from taking place, 
and the case may be cured in much less time than those 



Stimulation vs. Antiphlogistication. 269 

cases are generally cured. A great many years of ob- 
servation and practice in treating and curing many 
hundreds of such cases justifies these statements. 

" The following sketches are taken from a collection 
of essays on epidemic diseases collected by Dr. H. 
Sherrill : 

" In 1825 the remittent and typhus fever prevailed 
in many places along the Hudson River, in an epi- 
demic form, and more than commonly severe. Some 
sketches of a history of it was read at the annual meet- 
ing of the Duchess County Society that falL An ab- 
stract from it is here made : ' Generally the cases ex- 
hibited inflammatory action, but in many instances 
there was a small flaccid pulse, like that which often 
took place in the epidemic of 1812. There was dull or 
intense headache — dull appearance of the eyes — a lurid 
face — a tired aching of the limbs — the tongue was con- 
tracted, pointed, and very red, in some cases there was 
great prostration and congestion ; when the disease 
was not checked early, a state of typhus set in, and this 
might be tedious, obstinate, or fatal. 5 

" The most suitable treatment was, in the early stage, 
to use active means to remove congestion and an in- 
flammatory state ; for this purpose free blood-letting 
was the most useful remedy ; all the after-symptoms 
were shaped or controlled by the use or omission of 
this remedy. In those cases where there was great de- 
pression or cougestion, and the pulse was small and 
flaccid, as it generally is in such a state of disease, the 
portion of blood taken at first was small, and the oper- 
ation repeated, as was practiced in the epidemic of 1812 
and in that of 1793, as recommended and used by Dr. 
Rush ; in such a condition, the pulse always on bleed- 
ing rises and is more full and firm ■ the blood was very 



270 DlPTHERlA. 

black ; the medicine used was of a refrigerating, su- 
dorific nature. There were as many as twenty-five 
cases treated in this way (which was large for a sparse- 
settled country district) ; the fever run out, and a crisis 
formed the ninth day ; there were no stimulants given 
till after the crisis, and very little then ; nourishment 
was mostly relied upon to restore the strength. Many 
of the cases assumed a typhous state, but it was soon 
controlled ; there was not one case fatal. 

u In many instances, and in most places, from inform- 
ation received and reports made, attempts were made 
to cure this disease by alexipharmic remedies, such as 
mercury, opium, sudorific cordial, and alcoholic mix- 
tures, and those were freely used ; in this way a long, 
tedious illness ensued ; the case run on three, four, five, 
or six weeks ; the patient got a black tongue and teeth, 
stupor, delirium, nervous irritation, and a train of 
those symptoms called typhous ; frequently the case 
terminated in death. 

" It is a fair inference to make, that under similar 
treatment corresponding results would occur at this 
time. 

" Cases similar to those detailed, it appears, at this 
time may be cured or prove tedious and fatal accord- 
ing to the mode of treatment, as the following may 
show: 

"«R. I., Dec. 20, 1861. 

" c Took a cold, which increased so that on the 28th 
he took to bed with fever, pain in the head, nausea, 
soreness and aching of the limbs, rather prostrated press- 
ure of the chest. Jan. 2, 1862 : When I first saw him 
he was inclined to stupor — tongue contracted and red 
-r-bowels costive ; he appeared to have foaming con- 



Stimulation vs. Antiphlogistication. 27 L 

gestion of the brain or lung — pulse compressible, a 
beginning of the state called typhoid. 

" ' From the arm sixteen ounces of blood were taken ; 
it was black, and deprived of a required quantity of 
vital air ; it soon was as firm as liver ; means were used 
to open the bowels ; he was put upon the use of homeo- 
pathic medicine ; these were varied from time to time 
to operate on the symptoms presented. After the use 
of the first remedies, the pulse became more full and 
firm. This was the case, by such means, in the epi- 
demic of 1812, and in the epidemic cholera. He was 
given as much cold water as he would take ; he took 
no nourishment, except gruel or the like ; all stimu- 
lant and alcoholic articles were excluded ; the fever 
and disease gradually abated. On the 10th the fever 
subsided and a crisis formed, so that on the 12th he 
set up, and for a short time read the news ; the tongue 
retained a redness, attended with flushes of fever, so 
that remedies were still given to remove those symp- 
toms of a trail of inflammatory action ; even nourish- 
ment was sparingly given, and no alcoholic mixtures 
were allowed. He regularly improved, daily walked 
the room, and by the 20th went down stairs, fully 
cured. Medicijs.' 

" The following case took place about the same time 
as the preceding one. It was communicated by the 
nursery attendants : 

" A. B. was attacked precisely like the other. After 
about ten days' lingering was taken to bed with symp- 
toms similar to the preceding case. In four days he 
was greatly prostrated and distressed ; the tongue was 
very red and pointed ; it was now around that he had 
typhoid fever ; before the fever ended or a crisis formed 
lie was given beef-tea, and was soon put upon the use 



272 DlPTHERIA. 

of port wine ; he soon inclined to stupor and indiffer- 
ence ; by the advice of several doctors, called respect- 
able prescribers, the stimulants were increased ; a black 
scurf formed on the tongue and teeth, the edges of the 
tongue retaining a lively redness. To keep him from 
running down and sinking, brandy was added to the 
other means ; he was very uneasy, attended with ner- 
vous irritation and an impaired mind. In this way he 
struggled along for five weeks, and then died. 

" In a history of the epidemic of 1812, as it appeared 
in Duchess County, which was described as a remit- 
ting bilious fever, in many cases it was attended with 
inflammation and congestion of some of the internal 
organs. When not early checked or relieved, it was 
strongly inclined to pass into a state of typhus or gan- 
grene. In a township containing 2,400 inhabitants, 
there were about 130 cases. It was generally looked 
upon by the people and the medical men as a state 
of direst weakness and of a typhoid tendency, and re- 
course was had to a free use of a great variety of 
stimulants and alcoholic mixtures to keep off typhus, 
' to keep the patient from running down into typhus 
and gangrene.' A clergyman of the place set down 
the names of those who died. It footed 63 — one 
half! 

" In another district, of about the same population, 
there were about 150 cases of the same epidemic. 
They were treated bj free blood-letting and refrigerant 
remedies. No alcohol was used until the congestion 
and fever were removed and a crisis formed. Of 
these it is stated that ninety-four per cent, were cured. 

" Several years afterward the work of Surgeon-Gen- 
eral Mann and Prof. Gallup appeared, which treated 
on this epidemic of 1812. They advocated and recom- 



Stimulation vs. Antiphlogisticatiost. 273 

mended the same doctrine and practice which has just 
been mentioned, by which it appeared that in the army 
the proportion cured was over ninety per cent. 

" In those essays of Messrs. Mann and Gallup it is 
stated that in the vicinity of the army, among the 
people, a stimulant treatment for the epidemic fre- 
quently was used, and that one fourth to one half the 
cases were fatal, 

" In a report from Dr. Lovell, it is stated that in one 
village and vicinity where the stimulant practice was 
freely used, in the month of January, 1812, there were 
seventy-three deaths. During this time there were 
one hundred cases in the army, which were treated by 
blood-letting, etc., of which only three proved fatal. 

" With such glaring statements before us, is it not 
surprising that a great and obstinate prejudice against 
bleeding exists in the community ? By it, no doubt, 
many a one has lost his life. If the Sanitary Board 
of the army could be induced to review the facts, and 
they could be made to produce a fair influence on the 
general mind, many of the soldiers might have their 
lives preserved, who now fall victims to typhus, qui- 
nine, and alcohol, and the government might save the 
immense sums which these popular drugs cost." 

It would be difficult to compress a greater number 
of pathological errors and therapeutic mistakes into so 
small a compass. Scientifically, it is a mere " budget 
of blunders." But as it represents the theory and 
practice of about an equal moiety of the medical pro- 
fession of the whole civilized world, it is entitled to 
candid consideration and respectful refutation. 

Dr. Sherrill assumes that typhus is an effect of in- 
flammation, and that by promptly reducing the inflam- 
mation, that is, by employing bleeding and antiphlo- 

12* 



274 DlPTHEEIA. 

gistic drugs in the early stage, the consequential 
" typhous condition" may be averted. 

Nothing can be further from the truth, and no doc- 
trine could be more mischievous in practice. It has 
already slain its millions. Typhus or typhoid fever, 
or a " typhous condition," means nothing more nor less 
than a continued fever, with or without the concurrence 
of an acute local inflammation, in which the remedial 
effort is not chiefly and persistently determined to the 
whole surface of the body. If the determination of 
remedial effort — the a fever," or " reaction" of medical 
authors — is decidedly and permanently directed to the 
whole surface, the fever is properly called entonic or 
sthenic ; otherwise it is asthenic, atonic, or typhous. 
In all forms of remittent fever, diptheria, malignant 
scarlet fever, putrid or epidemic sore throat, the 
diathesis, both of the local and the constitutional dis- 
ease — the inflammation and the fever — is invariably 
atonic in all stages. The disease commences with the 
" typhous condition," progresses with the " typhous con- 
dition," and ends with the " typhous condition." And 
the effect of bleeding and other reducing processes and 
agents is always to aggravate the " typhous condition," 
and, when the patient is so lucky as to survive the 
disease and medication, to prolong the convalescence, 
and render recovery imperfect. 

Dr. Sherrill does well in objecting to alcoholic and 
other stimulants, notwithstanding we have a formi- 
dable array of authorities in their favor ; but he resorts 
to antiphlogistics because stimulants are injurious, he 
commits an error quite equal, and even more disastrous 
in results, to the mistake of those who recommend 
alcoholic stimulants because antiphlogistics are in- 
jurious. 



Stimulation vs. Antiphlogistication. 275 

Is there not something marvelously strange in this 
controversy ? Was the like of it ever heard of or 
thought of on the face of the earth ? Were scientific 
men ever in a similar muddle on any other subject ? 

Here is a learned body of men — 40,000 strong in 
the United States — divided into two classes nearly 
equal in number, character, and experience — one class 
condemning stimulants and approving antiphlogistics, 
and the other class condemning antiphlogistics and 
approving stimulants. And each party refers to its 
own observations and experience to prove that its own 
practice is all right, and that the opposite treatment is 
all wrong. What can such experience be worth ? 

And so the profession might go on another three 
thousand years, ravaging the human constitution with 
poisonous drugs, and sending the human race in con- 
stant droves to premature graves, and justify their 
doings by " observation and experience." Never, 
never will their destroying hand be stayed until a 
true theory is understood, by which the facts of observ- 
ation and experience may be judged and applied. 

Whether a stimulant or an antiphlogistic plan of 
treatment is most successful, or rather, whether one 
or the other is less injurious, depends entirely on the 
degree of atony or debility — on the greater or less 
degree of the asthenic or typhoid condition of the 
system. In ordinary cases there would be little to 
choose. In these cases the patient will recover in 
spite of a great amount of injurious medication, 
whether of the stimulant or the antiphlogistic kind ; 
and as the great majority of cases are of this charac- 
ter, the " success" of either plan, according to the 
ordinary operations of the law of chance, would be 
nearly equal. And this fact alone solves the problem 



276 DlPTHERIA. 

why it is that the advocates of the opposite plans of 
treatment can never agree. But in the mildest cases 
the stimulant plan would be worse than the antiphlo- 
gistic ; while in the severest cases the antiphlogistic 
treatment would be more fatal than the stimulant. 

The subject is, however, still further complicated 
by the different degrees or potencies of stimulation or 
antiphlogistication to which different physicians resort. 
Some of the stimulating doctors use mild stimulants 
in moderate doses, while others employ strong stim- 
ulants in large doses. And so with the antiphlogis- 
ticating practitioners. Some employ the most deadly 
reducing agents of the materia medica, while others 
prescribe only the milder poisons of the same class. 
All of these circumstances must be taken into the 
account in estimating the effects of either plan of treat- 
ment. And, I apprehend, the perfect understanding 
of the whole subject will bring the reader to the con- 
clusion that all physicians have come to, who have 
fully investigated the subject, viz. : the less drug-med- 
ication of any kind, the better for the patient. 



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R. T. TRALL, M.D., PRINCIPAL. 

The regular lecture terms commence on the second Monday of November in each 
year, and continue twenty weeks. Particular attention is devoted to Practical Anatomy. 
Dissections, and Obstetrical Demonstrations. This school is chartered by the Legisla- 
ture, and authorized to confer the degree of M. D. Fees for the whole course $75. 
Graduation fee $25. 



NEW YORK 

HYGEIO-THERAPEUTIC 

[OHARTEKED BY THE LEGISLATURE.] 



The Course of Lectures for the Winter Term will commence the second Monday 
in November of each year, and continue twenty weeks, including one week's 
vacation during the holiday season. 

FACULTY. 

R. T. TRALL, M.D., Institutes of Medicine, Theory and Practice, Materia 

Medica, Female Diseases, and Medical Jurisprudence. 
O. T. LINES, M.D., Anatomy and Surg fry. 
HULDAH PAGE, M.D., Physiology and Hygiene. 
A. K. EATON, M.D., Chemistry and Natural Philosophy. 
LYDIA F. FOWLER, M.D., Obstetrics. 

Dr. H. F. BRIGGS, Philosophy of Voice, Speech, and Gesture. 
L. N. FOWLER, A.M., Phrenology and Mental Science. 

CURATORS. 

G. F. ADAMS, M.D., Brooklyn, N. Y. 
JAMES 0. JACKSON, M.D., Dansville, N. Y. 
HULDAH PAGE, M.D., Augusta, Maine. 
O. T. LINES, M.D., Williamsburgh, N. Y. 
E. P. MILLER, M.D., New York. 

Fees for the whole Course, $75, payable in advance. Matriculation Fee, $5. 
Graduation Fee, $20. Candidates for the degree of M.D. are required to deposit a 
thesis on some medical subject, with the Graduation Fee, two weeks before the 
close of the term. 

Board can be had in the city for from $3 to $5 per week, according to rooms and 
other accommodations required. Students who prefer, can hire rooms and board 
themselves. 

Programme of Educational Exercises. 

Usually there will be Four Lectures daily, of one hour each. Half an hour, 
morning and evening, will be devoted to gymnastic and elocutionary exercises. A 
(Uinique will be held every Friday ; and on Saturdays the students will visit the 
hospitals and public institutions, where a great variety of surgical operations are 
performed, and where almost every phase of diseased and deformed humanity can 
be seen. There will be a Lyceum debate on Medical subjects one or two evenings 
of each week, with criticisms, essays, etc., by members of the class, for mutual 
improvement. One or two evenings of each week will be appropriated to music, 
dancing, and other wholesome exercises and recreations. 

For further information, address 

R. T. TRAIL, M.D., 

15 Laight Street, New York. 



; Books sent, Prepaid, by Mail, to ant Post-office in the United Stat*s. w 



A LIST OF WOllKS 



FOWLER AND WELLS, 308 BROADWAY, NEW YORK. 



In order to accommodate " the people" residing in all parts of the United States, the Pub- 
lishers will forward, by return of the first mail, any book named in the following list. The 
postage will be pre-paid at the New York office. The price of each work, including postage, 
is given, so that the exact amount may be remitted. Letters containing orders should be 
post-paid, and directed as follows : FOWLER AND W ELLS 

308 Broadway, New York. 



WORKS ON PHRENOLOGY. 



Combe's Lectures on Phre- 

noi.ogy. A complete course. Bound iu muslin, $1 25. 

Chart for Recording various 

Developments. Designed for Phrenologists. 6 cents. 

Constitution of Man. By 

Geo. Combe. Authorized edition, with Illustrations, 
embracing his Portrait. Muslin, 8T cents. 

Defence of Phrenology, 



Domestic Life, Thoughts on ; 

its Concord and Discoid. By N. Sizer. 15 cents. 

Education Complete. Em- 
bracing Physiology, Animal and Mental, Self-Culture, 
and Memory. One large vol. By Fowler. $2 50. 

Education, founded on the Na- 

tureofMan. By Dr. Spurzheim. Muslin, 87 cents. 

Familiar Lessons on Phre- 

nology and Physiology. An excellent work for 
Children. Beautifully Illustrated. $1 25. 

Marriage; its History and 

Philosophy, with directions for Happy Marriages. 
Bound iu muslin, ** cents. 

Matrimony ; or, Phrenology 

and Physiology applied to the Selection of Congenial 
Companions for !>*<e. By Fowler. 30 ceuts. 

Memory >nd Intellectual 

Improvement ; appJ'-d to Stlf-Educ-atiou. By Fowler. 
• Muslin, 87 cents. 

Combe's Moral Philosophy; 

i or, The Duties of Mao. By Geo. Combe. 87 cents. 



Mental Science, Lectures oi±, 

according to the Philosophy of Phrenology. By Rev. 
G. S. Weaver. Muslin, 87 cents. 

Phrenology Proved, Ilhis- 



Phrenological Journal, 

American, Monthly. Quarto, Illustrated. A year, $1. 

Phrenology and the Scrip- 

tures. By Rev. John Pierpont. 15 cents. 

Phrenological Guide. De- 
signed for the Use of Students. 15 cents. 

Phrenological Almanac. Il- 
lustrated with numerous engravings. 6 ceuts. 

Phrenological Bust : design- 

cd especially for Learners, showing the exact location 
of all the Organs of the Brain fully developed. Price, 
including box for packing, $1 25. [Not mailable.] 

Phrenological Specimens for 

Societies and Private Cabinets. 40 casts ; nett, $25. 

Self-Culture and Perfection 

of "Character. Muslin, S7 cents. 

Self-Instructor in Phrenol- 



Symbolical Head and Phre- 

nological Chart, in map form, showing the Natural 
Language of the Phrenological Organs. 30 cents. 

Complete Works of Dr. Gall 

on Phrenology. 6 vols., $7. 



; Tuk Poblishkrs would respectf ully refer Sti angers, Agents, and Country Dealers to tlue principal PtUAteftsrs 
lin New York, Philadelphia, Boston, or other ci ies, f;>r evidence of their ability to fulfill all contracts. Thejr ta*»o 
betn many years before the public, engagr* in the rublishing business in the city of NewYotk. 



Fowler and Wells's Publications. 



HYDROPATHY; OR, WATER-CURE. 



It the people can be thoroughly indoctrinated in the general principles of Hydropathy, and make them 
selves acquainted with the Lawb of Life and Health, they will well-nigh emancipate themselves from all 
»eed of doctors ef any sort.— Dr. Trall. 

By no other way can men approach nearer to the gods than by conferring health on men. — Cicero. 



Accidents and Emergencies. 

By Alfred Sniee. Notes by Trall. Illustrated. 15 cents. 

Children ; their Hydropathic 

Management in Health and Disease. Dr. Shew. $1 25. 

Cholera ; its Causes, Preven- 
tion, and Cure, and all other Bowel Complaints. SO c. 

Consumption ; its Causes, Pre- 

vention and Cure. Musliu, 8T cents. 

Cook Book, Hydropathic. 

With New Kecipes. Illustrated. ByK. T. Trall, M.D. 
Muslin, 87 cents. 

Domestic Practice of Hy- 
dropathy, with 15 engraved illustrations of important 

subjects from drawings. By E. Johnson, M.D. $1 50. 

Family Physician, Hydro- 

pathic. By Dr. Shew. A new and invaluable work 
for home practice. Profusely illustrated. $2 50. 

Hydropathic Encyclopedia : 

Illustrated. A Complete System of Hydropathy and 
Hygiene, embracing Anatomy, illustrated ; Physiol- 
ogy of the Human Body ; Hygienic Agencies, and the 
Preservation of Health ; Dietetics and Cookery ; The- 
ory and Practice of Treatment ; Special Pathology 
and Hydro-Therapeutics, including the Nature, 
Causes, Symptoms, and Treatment of all known Dis- 
eases ; Application to Surgical Diseases and to Hy- 
dropathy, to Midwifery and the Nursery. With Three 
Hundred Engravings, and nearly One Thousand 
Pages, including a Glossary, Table of Contents, and 
Index, complete. By R. T. Trail, M.D. Price, $3. 

Anatomical and Physiological Plates. These Plates were 

ai ■! anged expressly for Lecturers on Health, Physiology, etc. By Dr. R. T. Trail, M.D., of the New York Hydro- 
pathic College. They are six in number, representing the normal position and life-size of all the internal vis- 
cera, magnified illustrations of the organs of the special senses, and a view of the principal nerves, arteries, 
veins, muscles, etc. For popular instruction, for families, schools, and for professional reference, they will be 
found far superior to anything of the kind heretofore published, as they are more complete and perfect in art- 
istic design and finish. Price for the set, fully colored, backed and mounted on rollers, $12. [Not mailable.] 

Water-Cure Journal and Herald of Reforms. Devoted 

to Hydropathy, it3 Philosophy and Practice; to Physiology and Anatomy, with Illustrative engravings; to 
Dietetics, Exercise, Clothing, Occupations, Amusements, and those Laws which govern Life and Health. Pub- 
lished Monthly, at $1 a year in advance. 

Special List. We have, in addition to the above, Medical 

Works and Treatises on subjects which, although not adapted to general circulation, are invaluable to those who 
need them This Special List will be sent on application. 



Hydropathy: or, Water- Cure. 

Principles and Modes of Treatment. Dr. Shew. $1 25. 

Introduction to the Water- 

Curk. With First Principles. 15 cents. 

Philosophy of Water-Cure. 

By J. Balbirnie, M.D. A work for beginners. 30 c. 

Practice of Water-Cure. By 

Drs. Wilson and Gully. A handy, popular work. 30 e. 

Results of Hydropathy; 

treating of Constipation and Indigestion. By Ed- 
ward Johnson, M.D. £7 cents. 

Water-Cure in Chronic Dis- 
eases ; an exposition of the Causes, Progress, and Ter- 
minations of Various Chronic Diseases. By Dr. J. M. 
Gully. An important work. $1 50. 

Water and Vegetable Diet 

in Scrofula. Cancer, Asthma, etc. By Dr. Lamb. Notes 
by Dr. Shew. Muslin, 87 cents. 

Water-Cure in Every Known 

Disease. By J. H. Kausse. Muslin, 87 cts. 

Water-Cure Manual. A 

popular work on Hydropathy. Muslin, 87 cts. 

Water-Cure for the Mil- 

liox. 20 cents. 

Diseases of the J hroat and 

Lungs, including Dintheria. Bv Dr. Trall. 15 cents. 



Fowler and Wei. lb have all works on Hydropathy, Physiology, and the Natural Sciences generally. Book- 
sellers supplied on the most liberal terms. Agents wanted In every State, County, and Town. These works are 
universally popular, and thousands might be sold where they have never yet been introduced. Orders should be 
po«t-paid, and directed to the Publishers, as follows : FOWLER AND WEIjIjS, 

[Name the Po»t-omcs, Count y, and State.] 808 BROADWAY, New YORK. 



Fowler and Wells's Publications. 



PHYSIOLOGY-MESMERISM-PHONOGRAPHY. 



ON PHYSIOLOGY. 

Alcohol and the Constitu- 

tion of Man. Illustrated. By Youmans. 30 cents. 

Alcoholic Controversy. A 

Review of the Westminster Review on the Physiological 
Errors of Teetotalism. By Dr. Trail. 30 cents. 

Combe's Physiology, applied 

to the Improvement of Mental and Physical Educa- 
tion. Notes by Fowler. Muslin, 87 cents. 

Digestion, Physiology of. 

The Principles of Dietetics. By Andrew Combe. SO cts. 

Family Gymnasium. With 

numerous illustrations; Containing the most im- 
proved methods of applying Gymnastic, Calisihenic, 
Kiuesipathic, and Vocal exercises to the development 
of the bodily organs, the invigoration of then func- 
tions, the preservation ol health, and cure of dis- 
eases and deformities. By R. T. Trail, M.D. $1 25, 

Family Dentist ; a Popular 

Treatise on the Teeth. By D. C. Warner, M.D. 87 eta. 

Food and Diet ; containing an 

Analysis of every kind of Food and Drink. By Dr. J. 
Pereira. Muslin, $1 25. 

Fruits and Farinacea the 

Proper Food of Man. With Notes and engraved Il- 
lustrations. By R. T. Trail, M.D. Muslin, $1 25. 

Human Voice ; its "Right Man- 

agement in Speaking and Reading. 25 cents. 

Infancy; or, the Physiol ogi- 

cal and Moral Management of Children. Illustiated. 
By Dr, Combe. Muslin, 87 cents. 

Natural Laws of Man, 

Dr. Spurzheim. A good work. 30 cents. 

Philosophy of Sacred Histo- 

ky, considered in Relation to Human Aliment and the 
Wines of Scripture. By Sylvester Graham. $2. 

Physiology, Animal and Men- 

tal. applied to Health of Body and Power of Mind. By 
0. S. Fowler. Muslin, 87 cents. 

Sober and Temperate Life; 

with Notes and Illustrations by Louis Cornaro. 30 cts. 

The Science of Human Life. 

By Sylvester Graham, M.D. With a Portrait and Bi- 
ographical Sketch of the Author. $2 50. 

Tea and Coffee ; their Physi- 

cal, Intellectual, and Moral Effects. By Alcott. 15 cts. 

Teeth ; their Structure. Dis- 

ease, and Management, with Engravings. 15 cents. 



By 



Tobacco, Works on : compris- 
ing Essays by Trail, Shew, Alcott, Baldwin, Burdtll, 
Fowler, Greeley, and others. Complete in 1 vol. 62 c. 

Vegetable Diet, as sanctioned 

By Dr. 



MESMERISM-PSYCHOLOGY. 

Electrical Psychology, Phi- 
losophy of, in Twelve Lectures. By Dr. J. B. Dods. 
Muslin, 87 cents. 

Fascination ; or, the Philoso- 

phy of Charming (Magnetism). Illustrating the Prin- 
ciples of Life. Muslin, 87 cents. 

Library of Mesmerism and 

Psychology. With suitable Illustrations. In two 
large volumes of about 900 pages. Price, $3. 

Macrocosm and Microcosm ; 

or, the Universe Without and the Universe Within. By 
Fishbough. Scientific Work. Muslin, 87 cts. 

Philosophy of Mesmerism and 

Clairvoyance. Six Lectures, With Instructions. SO c. 

Psycholooy ; or, the Science 

of the Soul. By Haddock. Illustrated. 30 cents. 



ON PHONOGRAPHY. 

The Phonographic Instruc- 
tor. By Ben Pitman. Elementary. SO cents. 

The Manual of Phonography. 

By Pitman. A new and comprehensive exposition 
of Phonography, with copious illustrations and exer- 
cises. Useful for beginners. 60 cents. 

American Manual of Pho- 

nography ; being a complete guide to the acquisition 
of Short-Hand. By Elias Longley. 60 cents. 

Phonographic Teacher ; be- 
ing an Inductive Exposition of Phonography, with 
instructions to those who have not the assistance o( 
an Oral Teacher. By E. Webster. 45 cents. 

Phonographic Copy-Books, 

with Morocco Covers, for the use of students. f>0 cts. 

All works on Phonography will be furnished to order, 
by FOWLER AND WELLS, SOS Broadway, New York. 



Either of these works may be ordered and receiTed by return of the First Mail, postage prepaid by the Pub 
lUbers. Please address all letters, post-paid, to 

FOWLER AND WELLS, 
[Name the Port-offlce, County, and State.] 808 BROADWAY, N.EW YOBK, 



Fowler and Wells's Publications. 



MISCELLA NEOUS AND HAN D-BOOKS. 

When single copies of these works are wanted, the amount, in postage stamps, small change, or hank notes, 
may be inclosed in a letter and sent to the Publisher, who will forward the books by return of the fihst mail. 



MISCELLANEOUS. 

Alms and Aids for Girls and 

Young Women. By Rev. G. S. Weaver. Price, 87 c. 

CHEMISTRY, applied tO Physi- 
ology, Agriculture, and Commerce. By Liebig. 25 cts. 

Demands of the Age on Col- 

leges. An Oration. By Horace Mann. 25 ceuts. 

Delia's Doctors ; or, a Glance 

Behind the Scenes. By Miss Hannah Gardner Creamer. 
For the Family. Muslin, 87 cents. 

Fruit Culture for the Mill- 
ion ; or, Hand-Book for the Cultivation and Manage- 
ment of Fruit Trees. Illustrated with Ninety En- 
gravings. By Thomas Gregg. Muslin, 50 cts. 

Hints toward Reforms, in 

Lectures, Addresses, and other Writings. By H. 
Greeley. Second edition, with Crystal Palace. $125. 

Home for All; the Gravel 

Wall, a New, Cheap, and Superior Mode of Building, 
with Engravings, Plans, Views, etc. 87 cents. 

Hopes and Helps for the 

Young of Both Sexes. By Rev. G. S. Weaver. An 
excellent work. Muslin, 87 cents. 

Immortality Triumphant. — 



Kansas Region ; Embracing 

Descriptions of Scenery, Climate, Productions, Soil, 
and Resources of the Territory. Interspersed with 
Incidents of Travel. By Max Greene. 40 cents. 

Lectures on the Science of 

Human Life. By Sylvester Graham, M.D. $2 50. 

Diptheria, its Nature, History, 

Causes, Prevention and Treatment on Hygienic princi- 
ples ; with a Resume of the various theories and practices 
of the medical profession. By Dr. R. T. Trail, just pub- 
lished. Muslin, $1.25. J * 

Movement-Cure. Embracing 

the History and Philosophy of this System of Medical 
Treatment. Fully illustrated. By Geo. H. Taylor, 
M.D. $1 25. 

Physical Perfection ; or, 

the Philosophy of Human Beauty ; showing how to 
Acquire and Retain Bodily Symmetry, Health, and 
Vipror ; Secure Long Life ; and Avoid the Infirmities 
and Deformities of Age. An excellent work. $1. 

How to get a Patent, with 

Instructions to Inventors. 6 cents. 



Population, Theory of. The 

Law of Animal Fertility. Introduction by Trail. 15 cts. 

Saving and Wasting ; or, Do- 
mestic Economy Illustrated. By Solon Robinson. 87 c. 

The Right Word in the Right 

Place : A Pocket Dictionary of Synonyms, Technical 
Terms, Abbreviations, Foreign Phrases, etc. 50 cts. 

Ways of Life ; the Right Way 

and the Wrong Way. By Rev. G. S. Weaver. A cap- 
ital work. Muslin, 60 cents. 



NEW HAND-BOOKS. 

How to Write ; A Pocket 

Manual of Composition and Letter-Writing. Inval- 
uable to the young. Paper, 30 cents ; muslin, 50 cents. 

How to Talk ; A Pocket 

Manual of Conversation and Debate, with more than 
Five Hundred Common Mistakes in Speaking Cor- 
rected. Paper, 30 cents ; muslin, 50 cents. 

How to Behave; A Pocket 

Manual of Republican Etiquette, and Guide to Correct 
Personal Habits, with Rules for Debating Societies 
and Deliberative Assemblies. 30 cts.; muslin, 50 cts. 

How to Do Business ; A Pock- 

et Manual of Practical Affairs, and a Guide to Success 
In Life, with a Collection of Legal and Commercial 
Forms. Suitable for all. 30 cents ; muslin, 50 cents. 

Hand-Books for Home Im- 
provement (Educational) ; comprising " How to 

Write," "How to Talk," "How to Behave," and 
" How to Do Business," in one large volume. $1 50. 



RURAL HAND-BOOKS. 

Domestic Animals : A Man- 

ual of Cattle, Sheep, and Horse Husbandry; or, How 
to Breed, Rear, and Manage the Tenants of the Liarn- 
yard. Paper, 30 cents ; muslin, 50 cents. 

The Farm: A Manual of 

Practical Agriculture ; or, How to Cultivate all the 
Field Crops, with a most valuable Essav on Farm 
Management. Paper, 30 cents ; muslin, 50 cents. 

The Garden : A Manual of 

Horticulture ; or, How to Cultivate Vegetables, Fruits, 
and Flowers. Paper, 30 cents ; muslin, 50 cents. 

The House : A Manual of 

Rural Architecture ; or, How to Build Dwellings, 
Barns, and Out-Houses generally. 50 cents. 

Rural Manuals ; comprising 

"The House," "The Farm," " The Garden," and 
" Domestic Animals," in one large volume. $1 50. 



These works may be ordered in large or small quantities. A liberal discount will be made to Agents, and 
others, who buy to sell again. They may be sent by Express or as Freight, by Railroad, or otherwise, to any 
piace in the United States, the Canadas, Europe, or elsewhere. Checks or drafts, for large amounts, on New 
York, Philadelphia, or Boston, always preferred. We pay cost of Exchange. All letters should be post-paid, and 
addressed as follows : FOWLER AXD WELLS, 

[Name the Post-office, County, and State.] 308 BROADWAY New YORK. 



